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

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.