Back on Track Client Information Form

23 August 2022 | Posted in: Posts

Please read the Back on Track Agreement and provide electronic signature authorization below before submitting this form.

Back on Track only serves clients that live in the CV School District. Do you live in the CV School District?*
- Yes
- No
Name*
First Last
Date of Referral:*
MM slash DD slash YYYY
Are you behind on your rent?*
- Yes
- No
If yes, how much is your rent?
Are you behind on any utilities?*
- Yes
- No
If yes, how much can you afford to pay?
Have you received assistance from anyone else?*
- Yes
- No
If yes, what was the source of the assistance?
If yes, how much did you receive?
If yes, what was the last month assistance was received?
Please specify the reason you cannot pay rent and/or utilities*
Put NOT APPLICABLE if this question does not apply.
Date of Birth*
MM slash DD slash YYYY
Social Security #*
Current Address*
Street Address Address Line 2 City State ZIP Code
How long have you been at the current address listed above?*
Phone*
Email Address*
List all other household members, their ages, and their relationship to you*
If no other household members, put NOT APPLICABLE.
Please describe your needs*
Please list your expenses and amounts for each expense*
For example- food, car, utilities, insurance, etc.
Please list sources of income for household members and amounts for each*
Sources of income (earned income, SSI/DI, food stamps, TANF, etc.).
How did you hear about CVCCS Back on Track program?*
Authorization to contact Landlord
- Yes
- No
Landlord Name
Landlord Phone
Landlord Email (if known)
Landlord Address
I verify that the information I’ve provided is accurate. I have read, agree, and give my electronic signature authorization for the Back on Track Agreement:*
- I Agree
Email
This field is for validation purposes and should be left unchanged.

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2420 Gehman Lane, Lancaster, PA 17602
Get Directions | 717-208-3711

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

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Conestoga Valley Christian Community Services is a faith based 501c3 non-profit organization.