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(336)724-0023

The Potter's House FRC

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Client Intake Form

To register, please take the time to fill out the information below.

First Name

Last Name

Social Security/ITIN#

Email

Phone

DOB

Marital Status

Address

Relationship to Child/ren

Reason for Requesting Assistance

Employer

List All Income: SSI, AFDC, Foodstamps, Child Support, Alimony

(336)724-0023

Po Box 4221

Winston-Salem, NC 27115

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