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1 Crossroads – CTad- Woman New Family/Family Demographics Screen (fill-out once for entire family) Parent/Guardian1 Participant Last Name: __________________________________________First Name: __________________________________M.I._________ Proof of Identification: ___________________________________SSN: ______________________ DOB: ______________________ Marital Status: _____________________________________ Education Level: ____________________________________________ Parent/Guardian2 Last Name: __________________________________________First Name: __________________________________M.I._________ Proof of Identification: ___________________________________SSN: ______________________ DOB: ______________________ Marital Status: _____________________________________ Education Level: ____________________________________________ Caretaker Last Name: __________________________________________First Name: __________________________________M.I._________ Proof of Identification: ___________________________________ SSN: _____________________ DOB: _______________________ Marital Status: ____________________________________ Education Level: ____________________________________________ Physical Address: Street: _____________________________________________________________________________________________________ Street 2: ____________________________________________________________________________________________________ ZIP: ________________________ City: _________________________________ State: _______ County: ______________________ Proof of Residence: ___________________________________________________________________________________________ Homeless/Incarcerated Status: _____________________________________Migrant Status: ________________________________ Mailing Address: Street: ______________________________________________________________________________________________________ Street 2: ____________________________________________________________________________________________________ ZIP: ______________________ City: __________________________________ State: _______ County: _______________________ Telephones: Voter Registration: Telephone Number: __________________ Type: H, C, W, F, M Primary: _______Carrier: _______________________ Telephone Number: __________________ Type: H, C, W, F, M Primary: _______Carrier: _______________________ Military Status – Non-military, National Guard, Active Confidentiality: Communication Options: Language Read: ______________ Language Spoken: __________________ Interpreter Sign Language Interpreter Email Address: _____________________________________ Preferred Method of Contact: ________________________________ Family Assessment Screen (fill-out once for entire family) 1. Does anyone smoke inside your house? Yes

No 2. Has adequate household food storage and preparation? Yes No 3. Has household food insecurity? Yes No 4. Source of drinking water? City Not Sure Well Cistern Spring Other Where did you hear about WIC? ________________________________________ 37433_WIC_Ctad_FIN2.indd 1 37433_WIC_Ctad_FIN2.indd 1 7/31/20 3:00 PM 7/31/20 3:00 PM