Getting Ahead Application

Your name *

Last name

Email address *

Phone number

Phone type

MobileHomeWorkOther

Address

HomeWorkOther

Country

Country

Street Address

Apt/unit/box (optional)

City

State

Postal code

Gender

Select…MaleFemale

Birthdate

Please name ALL adults in household *

Please list the children in household *

please include name and age

Do your children live with you? *

yes

No

Are there other children in the household? *

I was referred to Getting Ahead class by *

Phone number *

Phone type

MobileHomeWorkOther

Employment

Place of employment *

Education

Highest grade completed *

1-6th

7-8th

10th

11th

12th

Assoc.

BA/BS

Master's

Currently enrolled in (education program) *

Income

Please select all sources of income *

Wages

TANF

SSI

Unemployment

Child support

none

Other

Total monthly income from all sources *

Transportation

Do you have a working vehicle? *

yes

no

Are you on a bus route?

yes

no

not sure

Please check the agencies you are currently working with

One stop

Head start

Energy assistance (OG&E, OHS, LIHP, Catholic charities, sec. 8)

Food stamps/SNAP/WIC

Free/reduced school lunches

Academic financial aid

TANF

Salvation Army

DRS vocational rehab

Adult education (GED)

Drug court

Celebrate recovery

Other

Please select the areas where you are experiencing difficulties:

Employment

Transportation

Training/education

Budgeting

Isolation

Housing

Alcohol/drugs

Dental/vision

Parenting

Legal

Healthcare costs

Boundaries

I certify that the following are true (check off) *

I am not in a major crisis (untreated mental illness or drug/alcohol addiction, domestic violence situation, homeless) I am fairly stable. (you can explain further in your interview

I give permission for Bridges staff to talk to referring source about participant's life situation, strengths, and barriers

I am willing to participate in an interview with Bridges staff. It is my responsibility to arrange childcare during the interview.

I am willing to commit to a 12-18 week training course. (Approx. three hours one night per week, childcare and dinner provided.)

Photo/video Release

If you are selected as one of our participants/investigators, do you authorize Bridges staff to use pictures and videos of yourself and your children for promotion and inspiration to others? *

Yes

No

NOTE

We will be serving a meal. If you have any food allergies, it is your responsibility to ask about ingredients. We are not responsible for any allergy or medical reaction you may have.

A signature will be required. When you sign, you are giving permission for us to exchange information with the above people if necessary. Information will be used to determine

This is an application for the Getting Ahead training; it does not guarantee you will be accepted. You will be contacted for an interview approximately one month prior to the next class starting. If your contact number changes after you have submitted this application, you are responsible for informing the Bridges staff as soon as possible.
Thank you!

Submit

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