Prosper Mentoring Interest Form
Please complete all answers in the below form. RUW will use this information to make sure that our programs reflect the diversity of the ALICE® Community that we serve. We will not publicize any of your specific information. When completed, please sign and submit the application to Rappahannock United Way.
Email *
First and Last Name *
Email Address *
Mailing Address *
City, State, Zip Code *
Primary Phone Number *
May we leave a voicemail or text for you? *
Birth Year *
Are you a Military Veteran? *
How many people currently live in your household? *
Please list all household members and ages *
What is your Ethnicity? *
What is your Race? *
Current Employment Status: *
If you are currently employed, what is your occupation and Company name: *
What is your household's (including all adults) annual gross income (before all deductions)? *
Are you satisfied with your current job?
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Do you have reliable transportation? *
Please select any of the following feelings you experience when discussing finances:
What is the best way to motivate you? *
What do you want to accomplish during this program? (List 3 financial / life goals) *
Are you able to commit to a 12-month program with monthly in-person workshops? (Graduation ceremony at the completion of program) *
If not, why?
Did someone recommend you apply to participate in Prosper Mentoring? If Yes, Who?
Please provide contact details for one person who can provide a reference for you -- someone who can speak to your readiness to participate in Prosper Mentoring. Please include the following: Full Name (First and Last), Phone Number, Email Address, and Relationship to You. *
Application Submission
* Electronic Signature Acknowledgement: By typing your name below you are completing this form using an electronic signature. You agree that your electronic signature has the same legal validity, meaning, and effect as your handwritten signature. *
Applicant Signature *
Today's Date *
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