Getting Ahead Class Application
Name
*
First Name
Last Name
Birthdate (00/00/0000 format):
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What is the best way to communicate with you?
*
How many adults live in your household?
*
How many children live in your household?
*
Please list all adults ages 18 and older in your household, with their ages, names and genders:
*
Please list names, ages and date of birth of all children in household (if applicable):
*
Please select any race/ethnicity that you identify with:
*
White/Caucasian
Black/African American
Native Hawaiian/other Pacific Islander
Latino
Indigenous American
Prefer not to disclose
Are you Hispanic?
*
Yes
No
Prefer not to disclose
What is your current employment status?
*
Employed fulltime (40 hours or more per week)
Employed part time (less than 40 hours per week)
Unemployed and currently looking for work
Unemployed and not currently looking for work
Student
Retired
Homemaker/Stay at home parent
Self-employed
Unable to work
Other
What is your current housing situation?
*
I am homeless or currently threatened with eviction
I am in transitional/temporary housing OR my current rent/mortgage is unaffordable (over 30% or income)
I am in housing that is safe and I can afford but it isn't in the best condion
I am in subsidized housing
I am in safe, affordable, unsubsidized housing
Other
What is your current level of income stability?
*
No income/basic needs are not met
Some income, but not enough to cover all of my bills each month
I can pay all of my bills with the assistance I receive (from government or other social services)
I can pay all of my bills with out assistance but still have debt or feel I cannot save
I have enough income to pay all of my bills, lower my debt and save for the future
What range does your total yearly household income level fall in?
*
Less than $20,000
$20,000-$34,999
$35,000-$49,000
$50,000-$74,999
$75,000-$99,999
Over $100,000
Please select any services/agencies you or your family currently use:
*
Food pantries
Free and reduced school lunches
TANF
WIC
SNAP
Catholic Charities
Section 8
Salvation Army
None of the above
Other
What is the highest level of education you have completed?
*
High School Diploma
GED
Some College
Associate's Degree
Bachelor's Degree
Graduate level Degree
Technical Certification
Other
If you have children in school, have you moved to a new home and transferred to a new school in the last 6 months?
*
I don't have kids in school
I have kids in school, but I haven't moved in the last 6 months
I have kids in school, and we have moved in the last 6 months, but we didn't have to transfer schools
I have kids in school, and we moved within the last 6 months, and we transferred to a new school.
Do you receive/qualify for Medicaid (SoonerCare)?
*
Yes
No
If you receive Medicaid (Soonercare), please enter your Medicaid # here:
*
On a scale of 1-10 (1 being the lowest and 10 being the highest) please rate your current amount of Hope in the following categories:
My children will have a better life than me:
*
Lowest
1
2
3
4
5
6
7
8
9
Highest
10
1 is Lowest, 10 is Highest
My grandchildren will have a better life than me:
*
Lowest
1
2
3
4
5
6
7
8
9
Highest
10
1 is Lowest, 10 is Highest
My life circumstances can get better:
*
Lowest
1
2
3
4
5
6
7
8
9
Highest
10
1 is Lowest, 10 is Highest
I am capable of making changes in my life:
*
Lowest
1
2
3
4
5
6
7
8
9
Highest
10
1 is Lowest, 10 is Highest
There are people who care about me:
*
Lowest
1
2
3
4
5
6
7
8
9
Highest
10
1 is Lowest, 10 is Highest
There are people willing to help me:
*
Lowest
1
2
3
4
5
6
7
8
9
Highest
10
1 is Lowest, 10 is Highest
My past does not have to define my future:
*
Lowest
1
2
3
4
5
6
7
8
9
Highest
10
1 is Lowest, 10 is Highest
I have dreams and goals for myself:
*
Lowest
1
2
3
4
5
6
7
8
9
Highest
10
1 is Lowest, 10 is Highest
Are there any areas in life that you are experiencing difficulties? Ex: employment, transportation, child care, healthcare etc.
*
Who are the adults in your household who will be attending class?
*
How did you hear about Getting Ahead classes at the Y?
*
Why are you interested and what do you hope to get out of the Getting Ahead class?
*
Which of the following classes would you like to attend:
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Earlywine Park YMCA on Wednesdays
Cole Community Center (NW Expressway) on Thursdays
North Side YMCA on Tuesdays
Restore OKC (Restore Participants Only)
Great Plains (Weatherford) YMCA on Tuesdays
Please share any food allergies, sensitivities or dietary restrictions, you or your family has (NA if there are none):
*
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