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Primary Language/Idioma
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English
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Name/Nombre
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First Name
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Last Name
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Do you have a cell phone?/Tiene un telefono celular?
*
Yes/Si
No, I only have a landline/No, solo tengo telefono de casa
Phone
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Email
Address
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Address Line 1
Address Line 2
City
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Armed Forces (the) Americas
Armed Forces Europe
Armed Forces Pacific
Army Post Office (U.S. Army and U.S. Air Force)
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State
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How did you hear about us?
Facebook Ad
Facebook Live
Do you receive any Government Assistance? Check all that apply (This will not affect your eligibility to take the course.) Marque todas las que correspondan (Esto no afectará su elegibilidad para participar en este curso.)
*
SNAP/EBT Food Stamps (CalFresh)
Medi-Cal (Medicaid)
SSI (Supplemental Security Income)
SSDI (Social Security Disability)
NSLP (National School Lunch Program)
Public Housing Assistance or Section 8 voucher
Lifeline
Other
I am not sure
None
-SNAP, EBT food stamps, and CalFresh provide assistance in purchasing food for the home. -Medi-Cal is health insurance provided by California. -Supplemental Security Income is government program that provides stipends to low-income people who are aged 65 or older. -Social Security program that pays monthly benefits to you if you become disabled before you reach retirement age. -National School Lunch Program is free or reduced meals at school. -Public Housing Assistance and Section 8 vouchers provide assistance with affordable housing. -Lifeline Program that provides free or low cost phone service
Please confirm if you would prefer to be contacted back via text message or phone call. For a faster response please choose to be contacted via text message. Por favor, confirme si prefiere ser contactado a través de un mensaje de texto o una llamada telefónica. Para una respuesta más rápida, elija ser contactado a través de un mensaje de texto
*
Text Message/Mensaje de Texto
Phone Call/Llamada Telefonica
Do you use any of the mobile carriers below?
T-Mobile
Metro by T-Mobile
Ultra Mobile
Mint Mobile
US Mobile
Ting
Tracfone
Net10-Wireless
Simple Mobile
Red Pocket
Republic Wireless
Google Fi
None of the above
Please select the times you are available to receive a call from us. Porfavor seleccione los horarios que esta disponible para recivir una llamada de nosotros
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Monday 9:00AM - 11:00AM
Monday 12:00PM - 2:00PM
Monday 3:00PM - 5:00PM
Tuesday 9:00AM - 11:00AM
Tuesday 12:00PM - 2:00PM
Tuesday 3:00PM - 5:00PM
Wednesday 9:00AM - 11:00AM
Wednesday 12:00PM - 2:00PM
Wednesday 3:00PM - 5:00PM
Thursday 9:00AM - 11:00AM
Thursday 12:00PM - 2:00PM
Thursday 3:00PM - 5:00PM
Friday 9:00AM - 11:00AM
Friday 12:00PM - 2:00PM
Friday 3:00PM - 5:00PM
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Campaign Name
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GCLID (Google Click Identifier)
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