NIBC Registration Form – Neighborhoods of Battle Creek (NIBC)

Your Name(Required)

First Last

Spouse's Name

First Last

Are you homeless?(Required)

Address(Required)

Street Address Address Line 2 City ZIP Code

Phone(Required)

Email

Please help us collect basic demographic information about you. This information will only be used in our general reporting and will not be linked to you contact information or used in any discriminatory manner. Please check the box that most closely resembles you.

Gender

Date of Birth(Required)

Housing(Required)

U.S. Citizen(Required)

Veteran(Required)

Disabled(Required)

Ethnicity(Required)

African American

Latino/Hispanic

Native American

Asian/Pacific Islander

Caucasian

Middle Eastern

Other

Please select all that apply

What other Ethnicity?(Required)

Number of Seniors (60+) in Household?(Required)

Number of Adults (18-60) in Household?(Required)

Number of children in Household?(Required)

Annual Household Income(Required)

If not comfortable answering, please enter 0.

(Part of the ALICE program; a person receiving bus passes to and from work through ALICE can also receive child care assistance OR transportation assistance, but not both)

(Part of the ALICE program; a person who receives bus passes for work can either get child care OR transportation assistance)