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Getting Ahead Application
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* Indicates required question
Email
*
Your email
Name (First & Last)
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Phone Number
*
Your answer
Street Address
*
Your answer
City, State, Zip
*
Your answer
How did you hear about Getting Ahead/ Who were you Referred by:
Your answer
Are you Hispanic or Latino?
*
Hispanic
Not Hispanic
Regardless of your answer to the prior question, please indicate how you identify yourself (Select one or more)
*
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Other
I do not wish to provide this information
Required
Do you have a disability?
*
Yes
No
Prefer not to answer
Is there a male over age 21 in your home?
*
Yes
No
Highest Grade Level Completed
*
K-5
6-8
9-12
GED
Associate's
Bachelor's
Master's
Current Income Source
*
Employment
Social Security
No income
Other
Required
Are you a Migrant Farm Worker
*
Yes
No
Place of Employment
Your answer
What is your monthly income amount?
*
Your answer
How many people live with you in your home?
1
2
3
4
5
6
7
8
Other:
Clear selection
How many people live with you over the age of 62?
*
Your answer
How many people live with you under the age of 18?
*
Your answer
If selected, will you need childcare while you attend Getting Ahead?
*
Yes
No
Maybe
Please list the name(s) of your child(ren) and ages
Your answer
Does anyone else in your home have income?
YES
No
Other:
Clear selection
Marital Status
*
Single
Married
Domestic Partner
Separated
Divorced
Widowed
Spouse/ Partner's name
Your answer
Have you received food from Common Heart in the last year? (Benton Heights Presbyterian, Mill Grove UMC, Wingate Baptist, Union UMC, Liberty Hill Missionary Baptist, Mineral Springs UMC, any of our pop up pantries, deliviery, walk in, etc)
*
Yes
No
BENEFITS: PLEASE CHECK ALL THAT APPLY IN THE PAST TWO MONTHS: (check all that apply)
*
TANF
Food Stamps
AHA/ Housing
WIC
Headstart
Section 8/ Rental Assistance
Vocational Rehab
Free/ Reduced School lunch
Food pantry
Childcare Assistance
Medicaid (children)
Medicaid (adults)
Attended a food pantry in the last 2 months
Homeless
None
Required
PLACE A CHECK NEXT TO THE AREAS WHERE YOU ARE EXPERIENCING DIFFICULTIES: (check all that apply)
*
Finding Employment
Maintaining Employment
Education/ Training
Legal Problems
Budgeting
Parenting
Housing
Transportation
Friendship/ Relationships
Isolation
Drugs/ Alcohol
Childcare
Healthcare Costs
Domestic violence
Struggles to provide meals for your family
Children in abusive situation
Severly Disabled
Illiterate Adults
Person living with AIDS
Other:
Required
ARE YOU CURRENTLY IN A STATE OF CRISIS? (i.e. HOMELESS, DOMESTIC VIOLENCE SITUATION, UNTREATED DRUG/ALCOHOL ABUSE, UNTREATED MENTAL HEALTHETC.)
*
Yes
No
ARE YOU CURRENTLY ON PAROLE OR PROBATION? (THIS WILL NOT AUTOMATICALLY DISQUALIFY YOU FROM THE PROGRAM - STATUS DOES NOT MATTER)
*
Yes
No
PLEASE PROVIDE A BRIEF DESCRIPTION OF YOUR CURRENT STRENGTHS/BARRIERS:
*
Your answer
PLEASE, TELL US A LITTLE ABOUT YOUR LIFE
Your answer
WHO DO YOU KNOW WHO IS EITHER APPLYING OR HAS PARTICIPATED IN GETTING AHEAD. PLEASE PROVIDE NAME AND RELATIONSHIP (IE, SPOUSE, CHILD, PARENT, FRIEND, ETC)
Your answer
Please check the following if you agree
*
I AM WILLING TO PARTICIPATE IN AN INTERVIEW WITH COMMON HEART STAFF AND/OR PROGRAM ADMISSION COMMITTEE.
I AM WILLING TO PARTICIPATE IN A 17 SESSION FOCUS EMPOWERMENT GROUP (APPROXIMATELY THREE HOURS PER SESSION)
BY CHECKING THIS BOX, YOU UNDERSTAND THAT YOU ARE APPLYING FOR ADMISSION INTO COMMON HEART'S GETTING AHEAD COURSE. COMPLETION OF THIS APPLICATION DOES NOT GUARANTEE THAT YOU WILL BE ACCEPTED INTO THE PROGRAM. EVALUATION OF APPLICATIONS WILL BE DETERMINED AFTER AN INTERVIEW HAS BEEN CONDUCTED. IF YOUR CONTACT INFORMATION CHANGES WHILE WAITING FOR ACCEPTANCE INTO THIS COURSE, PLEASE NOTIFY OUR OFFICE SO THAT WE MAY UPDATE YOUR RECORDS. UNTIL YOU HAVE OFFICIALLY RECEIVED A LETTER OF ACCEPTANCE FROM COMMON HEART, IT IS YOUR RESPONSIBILITY TO MAKE SURE THAT YOUR CONTACT INFORMATION ON FILE REMAINS CURRENT.
I UNDERSTAND THAT IF I AM ACCEPTED INTO THIS PROGRAM I AM EXPECTED TO ACTIVELY PARTICIPATE IN EACH CLASS. THIS WILL INCLUDE BUT IS NOT LIMITED TO, ADDING TO THE DISCUSSIONS, SHARING EXPERIENCE AND BEING AN ACTIVE LISTENER.
I UNDERSTAND THAT I AM ALLOTED TWO MISSED CLASSES. WHEN I MISS A SESSION, IT IS MY RESPONSIBILITY TO COMMUNICATE WITH THE FACILITATOR / CO-FACILITATOR TO MAKE UP THE MISSED CLASS. I ALSO UNDERSTAND THAT I MUST MAKE UP THE MISSED CLASS PRIOR TO ATTENDING THE NEXT SESSION.
FOLLOWING SUCCESSFUL COMPLETION OF THE 17 SESSION EMPOWERMENT GROUP, I AM WILLING TO BE PLACED ON A TEAM WITH ALLIES WHO HAVE AGREED TO WALK WITH ME ON MY JOURNEY OUT OF POVERTY.
Required
PLEASE CHECK THIS BOX IF YOU AGREE WITH THE ABOVE INFORMATION AND RECOGNIZE THAT CHECKING THIS BOX IS EQUIVALENT TO ADDING YOUR SIGNATURE IN AGREEMENT.
*
Yes
No
Thank you for your interest in Getting Ahead Ahead! Someone will be in touch with you soon. If you have any questions please call 704-248-2648.
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