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2. This program receives assistance from Cherry Hill Township’s Community Development Block Grant Program. The Program, funded by the U.S. Department of Housing and Urban Development (HUD), requires us to collect specific information about our program participants. This information will be kept confidential and will only be provided to HUD in summarized reports.

4. Program Participant's Name:*
6. Street Address*
8. Zip*
9. Phone Number*
11. Emergency Contact Name:*
12. Phone Number:*
14. Race of Program Participant (must check one):*

    1. White
    2. Black/African American
    3. Asian
    4. American Indian/Alaskan Native
    5. Asian White
    6. Black/African American & White

    1. Asian/Pacific Islander
    2. American Indian/Alaskan Native and Black/African American
    3. Other Multi-Racial
    4. Native Hawaiian/Other Pacific Islander
    5. American Indian/Alaskan Native & White
16. Ethnicity of Program Participant*

    1. Hispanic
    2. Non-Hispanic
18. Disability*

    1. None
    2. Mobility (walker/wheelchair)
    3. Other Type of Disability
20. Certification:*

    I attest that the information provided is true and correct to my knowledge. I understand the information listed on this form may be subject to verification by the Cherry Hill Township and/or by the U.S. Department of Housing and Urban Development (HUD), or their authorized representatives.

22. Date*
    Date

24. For a Chinese Rider Registration Form Click Here

    For a Spanish Rider Registration Form Click Here

Leave This Blank:


26. Submit

* indicates a required field