Introduction to Self Employment webinar Registration, 07/21/20, 12- 1pm

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If you require accommodations to participate in this class, please contact Jenn Dobransky- jenn.dobransky@maine.edu or 207-386-1664

Thank you for providing the following information. Your name and contact information will not be shared. Aggregate data is used for the purposes of reporting to our funders and measuring the success of our programs.

All fields are required on the registration form. Please contact Jenn Dobransky- jenn.dobransky@maine.edu or 207-386-1664 if you prefer a paper copy or have any questions. If you have taken a class with NVME recently, contact the trainer. Your registration information may already be on file.

You may be contacted in the future to provide feedback on your experience with NVME.

Name-first *

Name-middle

Name-last *

Date of Birth *

YYYY

Street Address *

City *

State *

Zipcode *

Email *

Phone number *

Alternate phone number

How did you hear about us? *

Sign me up for the email news about our programs? *

Yes

Required

Gender *

Female

Male

Undisclosed

Required

If you are of Franco American heritage descent, please check here.

Franco American

If you consider yourself Hispanic/Latino, please check here.

Hispanic/Latino

In addition, check one or more of the following.

White

Asian

Native Hawaiian or Pacific Islander

Black or African American

Native American or Alaska Native

Multi-racial or other

Work Status *

Employed

Self-Employed

Employed part-time or seasonal

Unemployed

Retired/semi-retired

Required

I have a disability that limits my work *

Yes

Required

I receive SSI, SSDI, or veterans disability? *

Yes

Required

I am a veteran, active duty military or reservist *

Yes

Required

I receive unemployment insurance (UI)? *

Yes

Required

I am actively looking for work *

Yes

Required

Education Information *

Did not complete high school

High school dimploma/HiSET/GED

College coursework

Trade School certificate

Associates Degree

Bachelors Degree

Post-bacculete coursework

Graduate degree

Other

Required

Are you currently enrolled in school? *

Yes

Required

If you are currently a student, what kind of program are you enrollled in?

HS/HiSET/GED

College prep

Trade School

Associates Degree

Bachelor Degree

Graduate Degree

Major field of study?

Are you a University of Maine Augusta student? *

Yes

Number of people in your household including you *

Total monthly Income for your household (from all sources) *

Health Insurance coverage (choose one) *

Self- if household of one insurance, select this

Some members

All household members

No one

Are you Head of Household? *

Yes

Are you a single parent? *

Yes

Do you receive food stamps? *

Yes

Do you receive TANF? *

Yes

Do you have savings? *

Yes

Do you have retirement savings? *

Yes

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