Recovery Support Center
Membership Form

Date Completed (This is the Enrolment Start Date)		
	    MM      /      DD      /      YYYY	

1.           First Name:		Middle Initial:		Last Name:		

2. Gender:       Male  	Female  	Transgender  	3. Birth Date:  mm/dd/year	       /          /		
4. SSN:		If you do not wish to give your  SSN or it is unknown, enter  999-99-9999	
5.   Highest Grade Completed	
Some schooling, no high school		High school diploma/GED		Associates degree		Other credential (degree, certificate)		
Some high school		Some college		College degree or higher		No formal education		

ADDRESS
6. Address Type:	Home      		Homeless		
 If Address Type is “Homeless”, only enter the city/town and zip code where usually located		
 Street Address:	 	Unit:	
 City/Town:	        	State:	Zip code:    	

DEMOGRAPHICS (Cultural Characteristics)
8. Are you Spanish/ Hispanic/Latino?	Yes      No                                                    	
9. What is your primary Ethnicity?  
   (For example, American, African, Chinese, Middle Eastern, Haitian, Cuban, Puerto Rican, etc.)
	Specify one:_______________________________________	
10. What do you consider your race?    (For example, White/ Caucasian, Black/African American, Asian, etc.)
  Specify all that apply to you:_________________________________________________________________________________________________________	
11. In what language do you prefer to read or discuss health related materials? 
      (For example, English, Spanish, Portuguese, Russian, Haitian Creole.)	Specify one:_______________________________________	

HOUSEHOLD CHARACTERISTICS – Default answers will be entered – Skip this section and got to Question 16	
12. Number of adults in household:	1	13. Number of children living in Household:	0	
14. Client Income:   $0	
INSURANCE (Return to Facesheet to access Insurance)	
15. Insurance Type:	Not Collected:	X                                                               Insurance Name:  Other		

16. Phone: Collected on paper only for membership, is not reported to state.	(_________)  __________-  _____________________