MDHA VOICE Center Financial Freedom Course Registration Form

MDHA VOICE Center Financial Freedom Workshop Registration

Fill out the form carefully for registration.
Participant Information
Name*

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Birth Date

MonthDayYear
If you reside at an MDHA property, which location?
Are you a current Section 8 voucher holder?

YesNo
What is your gender?

MaleFemaleOther
What is your marital status?

SingleMarriedDivorcedSeparatedWidow
What best describes you? Check all that apply.

Black/African AmericanWhiteHispanic, Latino or Spanish originAsianAmerican Indian or Alaskan NativeMiddle Eastern or North AfricanNative Hawaiian or other Pacific IslanderOther race, ethnicity or origin
What is your highest level of education?

Less than high schoolHigh school diploma or GEDSome college, no degreeAssociate's or bachelor's degreeGraduate or professional's degreeCertificate or licensureDon't know or other
Are you currently employed?

YesNo
If yes, for how long?
Do you receive SSI or SSDI?

YesNo
Do you have a current bank account?

YesNo
Do you have any accounts in collections?

YesNo
If yes, how many? This can be an estimate.
Do you know your current credit score?

YesNo
What is your expectation of the VOICE Center Financial Freedom Workshop?
Do you have a financial goal? (Examples: get out of debt, purchase a car, pay off collections, become a homeowner, save for college)
Confidentiality Statement

All information shared on this registration is confidential. Information will be viewed by program facilitators from the MDHA VOICE Center and Dominion Financial Management, Inc. All information will be used for program evaluation only. This will help make the program better for you and future participants.
PHOTO RELEASE: I AGREE to allow my photograph to be taken and used by MDHA and Dominion Financial Management, Inc. in print, online and/or video for marketing materials.
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MDHA VOICE Center Financial Freedom Workshop Registration

Participant Information