BRIEF REGISTRATION Today's Date: ____/____/____
To help us better serve you and our diverse client population, please complete this information as accurately as possible.
1. PRIMARY LAST NAME: SECONDARY LAST NAME:
2. FIRST NAME: _____________________________ MIDDLE NAME ____________________________
3. SEX: ___ FEMALE ___ MALE
4. DATE OF BIRTH: ______/ ______/ _______
(month) (day) (year)
5. Address: _______________________________________________________________________________
____________________________________ ___________________ _______________
City State Zip Code
6. City/County ___ Fairfax City ___ Loudoun (Sterling)
___ Fairfax County ___ Prince William
___ Arlington ___ Manassas City
___ Alexandria City ___ Manassas Park
___ Falls Church City ___ Out of State
If another county in Virginia, please write in the name of the county ___________________
7. Home phone: ________________________ Cell phone:
Work phone: ________________________ Email Address:
8. What language do you usually speak at home:
___ Arabic ___ Farsi ___ Laotian ___ Thai
___ Cambodian ___ French ___ Somali ___ Urdu
___ Chinese/Mandarin ___ Korean ___ Spanish ___ Vietnamese
___ English ___ Kurd
If not listed, primary language spoken at home __________________________
9. RACE: ___ American Indian / Alaskan Native
___ Asian
___ Black
___ Hawaiian or other Pacific Islander
___ White
10. Country of birth: ___________________________________
11. Are you of Hispanic descent: ____ Yes ____ No
12. Marital Status: ___ Single ___ Widowed
___ Married ___ Divorced
___ Separated ___ Unmarried Couple
AVATAR-PHS-10 Rev. 7/1/11
