Client Registration & Intake Form

Guest Registration and the Client Intake Assessment combined into one form — no separate registration needed.

All answers will populate as records in CBP Connect. Please ensure all answers are correctly spelled and detailed to ensure accuracy in the database.

Registration Details

First Name *

Last Name *

Date of Birth *

Phone *

If the guest has no valid phone number, enter (000) 000-0000.

Preferred Language

Region / Service Area *

City *

County *

Which Program(s) would you be interested in? (select all that apply)

Device Accessibility ProgramAdult Digital SkillsDigital Skills for FamiliesMedical AssistancePhlebotomyFiber Optics

Partner Referral / Location

Intake Assessment

Client ID

Start Date/Time of Assessment

End Date/Time of Assessment

Next Appointment

Age Group

Housed-Unhoused

Current Corrected Address

Street Address

Zipcode

State

Race

Ethnicity

Gender

Are you a veteran?

Is the head of the household female?

Which Program(s) (select all that apply)

Adult Digital SkillsDigital Skills for FamiliesMedical AssistanceDevice Accessibility ProgramPhlebotomyFiber Optics Certification

Program Affiliation

Does the client have an email?

Do you have a cell phone?

Do you have internet access, at home?

What is the price range of your monthly internet

Do you know about the Affordable Connectivity Program (ACP)?

Were you registered to the Affordable Connectivity Program (ACP)?

Were you aware of the ACP wind-down?

How would you describe your digital skill level?

Device Accessibility Program

Digital Skills for Families

Adult Digital Skills

Medical Assistance

MMC Phleb

ETM Phleb

Family Members

What Devices

What is your primary form of transportation?

Current Residency

ID Types

In order to secure you employment, can you pass a drug test?

Criminal background

Have you been incarcerated?

Special Requirements or Barriers

Do you have a bank account?

(OLD) How many people live in your household?

How many people live in your household?

What is your annual household income?

Income Level

Govt. Programs (select all that apply)

FoodFood Stamps (SNAP)MedicaidSection 8 / Federal Public Housing AssistanceSocial Security Disability Insurance (SSDI)Supplemental Security Income (SSI)Temporary Assistance for Needy Families (TANF)Type a Lifeline Assistance (Obamaphone / Assurance Wireless)Unemployment BenefitsWomen, Infants and Children Program (WIC)NoneOther

Essentials Assist. (select all that apply)

Personal CareChild CareFoodClothingOtherNone

Assistance Agreement

Do you use telehealth?

Do you need assistance with any health-related concerns?

Are you interested in obtaining a degree/diploma, vocational training and/or certifications?

What is your highest level of education?

Are you currently employed?

10-Step (select all that apply)

Digital IDDigital LiteracyTransportationHousingWork ReadyFinancial LiteracyEssentialsHealthcareEducationEmploymentNone

CBP Intake Case Notes

Guest Resource Leads & Referrals

Partner Referral Notes

Referred to?

Participant Acknowledgement

I have reviewed and agree to the CBP Connect Terms, Privacy Notice, and Consent to Information Processing (Last Updated September 16, 2026).

I understand that information I submit may be collected, stored, used, and shared by The CARDBoard Project to evaluate eligibility, coordinate referrals, deliver services, track outcomes, and meet grant, audit, and legal requirements. The CARDBoard Project does not sell participant information.

I understand that information submitted through CBP Connect may be processed by artificial intelligence (AI) and automation tools to assist authorized staff, and that human review remains responsible for final decisions.

I consent to receive communications about program participation, applications, service coordination, and follow-up by email, telephone, SMS/text, postal mail, or electronic forms. I may opt out of non-essential text messages at any time.

I agree that electronic acknowledgements and signatures have the same legal effect as handwritten signatures, and I understand that submitting information does not guarantee eligibility, services, equipment, or enrollment.

I certify that the information I provide is accurate, complete, and truthful to the best of my knowledge. Where applicable, I represent that I am authorized to provide information and consent on behalf of the participant.

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Check all 6 acknowledgement boxes above to continue.