Name *

First Name

Last Name

Phone *

(###)

###

####

Gender

Male

Female

Race/Ethnicity

Black

Hispanic/Latino

Asian

White

Other

Marital Status

Married

Divorced

Separated

Single

Current Housing Situation

Homeless

In Shelter

In Transitional Living

In Wellness Hotel

Staying with Friends/Family

Rental Housing (not subsidized)

Subsidized Housing

Own a Home

Are you currently in any educational programs?

Yes

No

Highest level of education attained:

Less than High School

High School Graduate / GED

Some College

Associate's Degree

Bachelor's Degree

Graduate Degree

Are you currently employed?

Yes

No

Will you be able to attend all 16 sessions? *

Yes

No

What would prevent you from attending all 16 sessions?

Check all that apply

Work

School

Health

Transportation

Other

What location(s) would you be willing to attend?

Highland High School (English/Spanish): M&W, from 5-7:30pm

Refuge Church (English/Spanish): M&W, from 6-8:30pm

New City Church (English only): T&Th, from 6-8pm

Check all that apply:

I want to get ahead in life and am committed to that goal.

I am open to receiving support from volunteers.

I am willing to create relationships with the group.

I am willing to share both my strengths and my needs with others.

I am interested in leadership development and community involvement.

I understand that attendance is a requirement of participating in the Getting Ahead program and I am willing to regularly attend.