Connect with a Bridge Family Navigator Usted necesita ser contactado por un Navegador que habla Español?(Do you need to be contacted by a Spanish-speaking Navigator?) Yes No Full Legal Name(Required) First Last What name do you go by?Phone Number(Required)Email Address(Required) Address(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code In which county do you live?(Required)DouglasWashingtonDodgeSaundersSarpyPottawattamieOtherRace/Ethnicity (select all that apply)(Required) Native American or Alaskan Native Asian Black or African American Hispanic or Latino Middle Eastern or North African Native Hawaiian or Pacific Islander White Prefer not to say Prefer to self identify Sex(Required) Male Female Prefer not to say Your Date of Birth(Required) Total number of adults in the household(Required)Are you currently pregnant or expecting a child? (Mother or Father)(Required) Yes No Expected Due Date Based on the number of individuals in your household, is your income below 200% of the poverty level?(Required) Yes No What is the highest level of education you have completed?(Required) Less than high school High school diploma or GED Some college, no degree Certificate or trade credential Associate degree Bachelor's degree Graduate or professional degree Prefer not to answer Do you currently have any health insurance?(Required) Yes, Private/ACA Yes, Medicaid Yes, Medicare Medicaid in Process (application filled out) No Choose not to answer Do you have a disability?(Required) Yes No Does your child have a disability? Yes No Minor Assent(Required)(Only complete if the participant is a minor, if the participant is NOT a minor select N/A): "As a minor participating in this program, I give permission for my information to be shared and used to help improve the program." Yes No N/A Number of Children(Required)None123456789101st Child's first and last name(Required)List the first and last name for each child, under age 19, living in your home.1st Child's date of birth(Required) 2nd Child's first and last name(Required)List the first and last name for each child, under age 19, living in your home.2nd Child's date of birth(Required) 3rd Child's first and last name(Required)List the first and last name for each child, under age 19, living in your home.3rd Child's date of birth(Required) 4th Child's first and last name(Required)List the first and last name for each child, under age 19, living in your home.4th Child's date of birth(Required) 5th Child's first and last name(Required)List the first and last name for each child, under age 19, living in your home.5th Child's date of birth(Required) 6th Child's first and last name(Required)List the first and last name for each child, under age 19, living in your home.6th Child's date of birth(Required) 7th Child's first and last name(Required)List the first and last name for each child, under age 19, living in your home.7th Child's date of birth(Required) 8th Child's first and last name(Required)List the first and last name for each child, under age 19, living in your home.8th Child's date of birth(Required) 9th Child's first and last name(Required)List the first and last name for each child, under age 19, living in your home.9th Child's date of birth(Required) 10th Child's first and last name(Required)List the first and last name for each child, under age 19, living in your home.10th Child's date of birth(Required) What are some ways we can help you?Need(Required)What is your most urgent need? Check all that apply. Daily Living (telephone, clothes, hygiene) Dentist Education Finances General Life Skills Housing Legal Help Mental Health Parenting Assistance Substance Abuse Supportive Relationships Transportation Utilities Other What resource(s) are you looking for not listed above?(Required)Please describe your need.How did you find us?Who referred you to The Bridge?(Required)What school district(s) do your children attend?Check all that apply. Omaha Public Schools Millard Public Schools Ralston Public Schools Westside Community Schools Other What is the best time of day to contact you?Check all that apply. Morning Afternoon Evening after 5:00 p.m. ConsentCan The Bridge add your information to the Find Help database? Yes No CAPTCHA Connect with a Family Navigator X/TwitterThis field is for validation purposes and should be left unchanged.A little about youYour NameWhat name do you go by?Full Legal Name(Required) First Last Race/Ethnicity (select all that apply)(Required)Native American or Alaska NativeAsianBlack or African AmericanHispanic or LatinoMiddle Eastern or North AfricanNative Hawaiian or Pacific IslanderWhitePrefer not to sayPrefer to self identifySex(Required)MaleFemalePrefer not to sayAre you currently pregnant or expecting a child? (Mother or Father)(Required)YesNoPrefer not to sayTotal number of adults in the household(Required)Please enter a number from 0 to 10.Based on the number of individuals in your household, is your income below 200% of the poverty level? (Required)YesNoWhat is the highest level of education you have completed?(Required)Less than high schoolHigh school diploma or GEDSome college, no degreeCertificate or trade credentialAssociate degreeBachelor's degreeGraduate or professional degreePrefer not to answerDo you currently have any health insurance?(Required)Yes, Private/ACAYes, MedicaidYes, MedicareMedicaid in Process (application filled out)NoChoose not to answerDo you have a disability?(Required)YesNoDoes your child have a disability?YesNoMinor Assent (Only complete if the participant is a minor, if the participant is NOT a minor select N/A): "As a minor participating in this program, I give permission for my information to be shared and used to help improve the program.(Required)YesNoN/ADate of Birth(Required) Number of Children(Required)How many children live in the household?1st Child's first and last nameList the first and last name for each child, under age 19, living in your home. 1st Child's date of birthList the birthday for each child, under age 19, living in your home. 2nd Child's first and last nameList the first and last name for each child, under age 19, living in your home. 2nd Child's date of birthList the birthday for each child, under age 19, living in your home. 3rd Child's first and last nameList the first and last name for each child, under age 19, living in your home. 3rd Child's date of birthList the birthday for each child, under age 19, living in your home. 4th Child's first and last nameList the first and last name for each child, under age 19, living in your home. 4th Child's date of birthList the birthday for each child, under age 19, living in your home.5th Child's first and last nameList the first and last name for each child, under age 19, living in your home. 5th Child's date of birthList the birthday for each child, under age 19, living in your home. 6th Child's first and last nameList the first and last name for each child, under age 19, living in your home. 6th Child's date of birthList the birthday for each child, under age 19, living in your home. 7th Child's first and last nameList the first and last name for each child, under age 19, living in your home. 7th Child's date of birthList the birthday for each child, under age 19, living in your home. 8th Child's first and last nameList the first and last name for each child, under age 19, living in your home. 8th Child's date of birthList the birthday for each child, under age 19, living in your home. 9th Child's first and last nameList the first and last name for each child, under age 19, living in your home. 9th Child's date of birthList the birthday for each child, under age 19, living in your home. 10th Child's first and last nameIf there are more than ten children under age 19 living in your home, list them at the end of this form. 10th Child's date of birthList the birthday for each child, under age 19, living in your home. First and Last Name of all children listed aboveIf you have no children in the household, type N/APhone Number(Required)Email Address(Required) Address(Required) Street Address City State ZIP / Postal Code County(Required)What are some ways we can help you?Need(Required) Daily Living (telephone, clothes, hygiene) Dentist Education Finances General Life Skills Housing Legal Help Mental Health Parenting Assistance Substance Abuse Supportive Relationships Transportation Utilities Other What is your most urgent need? Check all that apply.Usted necesita ser contactado por un Navegador que habla Español? Yes No If you chose "Other", please specify your needs.Provide need detailsHow did you find us?Who referred you to The BRIDGE?(Required)What school district do your children attend? Omaha Public Schools Millard Public Schools Ralston Public Schools Westside Community Schools Other Check all that apply. What is the best time of day to contact you? Morning Afternoon Evening after 5:00 PM Check all that apply. Consent Yes No Can The BRIDGE add your information to the Find Help database? CAPTCHA
