HARRIS COUNTY PRECINCT ONE VETERANS REGISTRATION
Welcome Veterans!
The Harris County Precinct One veteran's registration is an additional way to establish contact with our Veterans and connect them with our programs, and resources from Precinct One.
This critical information will also contribute to building specific data from our veterans, allowing us to develop initiatives according to their needs; refer them to resources, and develop strategic and robust outreach.
Precinct One works to provide area constituents with opportunities regarding quality and accessible health, educational and recreational services through structured activities, all designed to inform and empower communities in the development and enhancement of the quality of life.
First Name*
Last Name*
Address
Address 2
City
State
Zip*
Email*
Phone
Date of Birth
Gender
Race
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Hispanic, Latino, or Spanish
Prefer not to say
Hispanic, Latino, or Spanish, White
Black or African American, White
Native American or American Indian
Other Race
Asian or Pacific Islander
Native American or American Indian, Hispanic, Latino, or Spanish
Black or African American, White, Other Race
Middle Eastern or North African
Native American or American Indian, Other Race
Black or African American, Other Race
Black or African American, Native American or American Indian
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Hispanic, Latino, or Spanish
Black or African American
Prefer not to say
Asian or Pacific Islander
Black or African American, White
Native American or American Indian
White
Other Race
Hispanic, Latino, or Spanish, White
Black or African American, Native American or American Indian, White, Other Race
Black or African American, Hispanic, Latino, or Spanish
Asian or Pacific Islander, Black or African American
Asian or Pacific Islander, Black or African American, Hispanic, Latino, or Spanish
Other
Black or African American, White, Other Race
Asian or Pacific Islander, Black or African American, White
Native American or American Indian, Hispanic, Latino, or Spanish
Marital Status
Married
Divorced
Single
Other
Annual Household Income
$0 - $24,999
$25,000 - $49,999
$50,000 - $74,999
$75,000 - $99,999
More than $100,000
More than 85.000
$75,000- $100,000
$50,000-75,000
$25,000 - $50,000
$0 - $25,000
Employment Status
Freelance
Full-time
Part-time
Unemployed
Retired
Would you like to receive information about registering to vote?
Yes
No
Are you currently experiencing homelessness?
Yes
No
House
Housing Situation
Rent
Own
Other
Live with relative
Owner
Roommate
Living with someone
Are you looking for Rental Assistance?
Yes
No
Are you looking for help to pay bills?
Yes
No
Household size or people living at home
1
2
3
4
5
6
7 or more
In what branch of the military do you belong?
Army
Navy
Marines
Air Force
Coast Guard
Other
Please state your last rank held prior to discharge.
If you belong to any veterans organizations or associations, please list them below:
Are you receiving any of the following benefits?
SSI (Supplemental Security Income)
TANF (Tempoary Assistance for Needy Families)
SNAP (Supplemental Nutrition Assistance Program)
Medicaid
None
Other
U.S. Military Pension
Do you have any Disabilities?
Yes
No
Do you have health insurance?
Yes
No
Would you like to receive information about signing up for the COVID-19 vaccine?
Yes
No
Please verify your request*
Submit