Getting Ahead in a Just-Gettin'-By World Application

Getting Ahead in a Just-Gettin'-By World Application

This is an application for the Getting Ahead training; it does not guarantee you will be accepted. You will be informed of your acceptance to this class 1-2 weeks before class begins. If your contact number changes after you have submitted this application, you are responsible for informing ConnectioN Point as soon as possible. All sessions will be held in person at ConnectioN Point, 1333 N 33rd St Lincoln, NE each Thursday from 12:30-2 pm beginning on June 2 and running until August 11. For questions call (402)413-0017. Thank you!
Name *
Date of birth *

Month Day Year
Date
Address *
Primary Phone Number *
Email *
example@example.com
Please list any children you plan to bring to class and would need childcare for:
Child #1 Name & Age
Child #2 Name & Age
Child #3 Name & Age
Child #4 Name & Age
Child #5 Name & Age
I was referred to this class by: *
Place of employment (if applicable)
Job title
Length of employment
Highest Grade Completed in School *
If you're currently enrolled in school, which school and program?
Please select all sources of income you currently have: *

ADC SSI Child Support Unemployment benefits Disability benefits Wages from a job Other
Total monthly income from all sources *
What method of transportation will you be using to get to class? *
Please check the agencies you are currently working with *

Head Start and/or Title XX Energy Assistance Food stamps/SNAP/WIC Academic Financial Aid TANF/ADC Salvation Army Vocational Rehabilitation Adult education (GED) Drug Court Lincoln Housing Authority/Section 8 None Other
Place a check next to the areas where you are experiencing difficulties *

Employment Isolation Parenting Transportation Housing Legal Training/education Alcohol/drugs Healthcare Budgeting/Finances Mental health Boundaries
What are your expectations of this class? What do you hope to learn/achieve? *
I certify that the following are true (check) *

I am not in a major crisis (untreated mental illness or drug/alcohol addiction, domestic violence situation, homeless); I am fairly stable and can be appropriate in a group setting. I am willing to commit to an 11-week training course. Approx. two hours per week, childcare provided only if requested
PHOTO/VIDEO RELEASE

If you are selected as one of our participants/Investigators, do you authorize ConnectioN Point staff to use pictures and videos of yourself and your children for promotion and inspiration to others? (Check this box if your answer is "yes.")
When you sign this page, you are giving permission for us to utilize your application to determine eligibility for the Getting Ahead in a Just-Gettin'-By World initiative and track progress toward goals.
Signature *

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