Building One Community -

This application is for:*

B1C Number (If known)

How did you hear about B1C?*

Second Last Name

Mobile Phone*

Other Phone

Your Email

Birthday*

Gender*

Emergency Contact

Phone

Relationship

Further information about you

Ethnicity*

Race*

What is your preferred language?*

What country were you born in?*

Year arrived in the US*

Year arrived in Fairfield or Westchester County*

Marital Status

Education Completed*

Employment Status*

WhatsApp Status Updates

We also update our WhatsApp Status regularly to inform about our upcoming programs and events and other community announcements. Please save our B1C Outreach number (475) 333-9216 in your contacts to view those WhatsApp Status updates.

Media Policy

We have engaged a photographer to take photos during our programs, classes, and when providing services at Building One Community (B1C). These photos will be used for B1C marketing purposes, including, but not limited to, the website, brochures, digital newsletters, social media, posters, and other printed materials and will not be sold or licensed to any third parties unaffiliated with B1C. If you have children under the age of 18 years and do NOT want your child’s photo to appear in B1C's marketing materials, please email us their names at [email protected]

Information about your children

Please list any children under the age of 18 who live in the United States. Please provide them in the order of birth.

Child 1 Information

Second Last Name

Relationship to child*

Child's birthdate*

Gender*

School*

Child 2 Information

Second Last Name

Relationship to child

Child's birthdate

Gender

School

Child 3 Information

Second Last Name

Relationship to child

Child's birthdate

Gender

School

FOR INTERNAL USE ONLY

Staff members, please provide your name if you helped fill out this form.

Comments

This field is for validation purposes and should be left unchanged.

B1C Intake Form

Emergency Contact

Further information about you

WhatsApp Status Updates

Media Policy

Information about your children

Child 1 Information

Child 2 Information

Child 3 Information

FOR INTERNAL USE ONLY