Prosperity Community Outreach, Inc.

Empowering today's youth to become tomorrow success stories

Social Services

Prosperity Community Outreach, INC

A Non-Profit Organization

425 Aldine Bender ste.C

Houston, TX 77060

281-448-5700

www.prosperitycommunityoutreach.com

 

 

Hoilday Season Client Intake Form

 

Name: _________________________                 Spouse Name: _______________________

DOB: _______                                                        DOB:  ________

Male___ Female___                                             Male___ Female___

Address: ______________________________________________________________

Phone: ________________________________________

             This number must be a valid contact number / Este número debe ser un número de contacto válido

Last 4 of SS#: ___________________________________________

Email: __________________________________________

 

# of children ___       # of people in household ___

#de niños                   # de personas en el hogar

 

 

Children  Names                                Ages           Birthday                         Grade level

Los nombres de los niños           de edad      de cumpleaños             nivel de grado    

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

 

 

Annual Household Income: _________

Anual ingresos de hogares

 

Would you like to be added to our mailing list for future assistances?  Yes__or No___

¿Le gustaría ser agregado a nuestra lista de correo para asistencias futuras?