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1 Crossroads – CTad-Child 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: Address:_____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 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: _______________________ 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 5. Where did you hear about WIC? ________________________________________ 37433_WIC_Ctad_FIN2.indd 5 37433_WIC_Ctad_FIN2.indd 5 7/31/20 3:00 PM 7/31/20 3:00 PM