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Clement Care Portal Registration
Username
Password
Confrm Password
User Role
Requester
Responder
Both
First Name
Last Name
Email
Contact Number
Home Zip Code
Category
--Select Category--
Appliance
Baby Care Item
Bedding/Furniture
Car Seat/Stroller
Clothing
Food/Groceries
Home Repair
Other
Rent/Utilities
School Supplies
Organization Info
Social Worker
Ministry Leader
Ministry Leader
Others
Ministry Leader
Organization Type
Ministry
Other
DFCS
Organization Name
Address 1
Address 2
City
State
Zip Code
Main Phone Number
