Family Success Center - Interest Form
Please complete this brief interest form and an FSC staff member will follow up with you soon. We look forward to having you join FSC!!
Email
*
example@example.com
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
What services are you seeking from the Family Success Center?
*
Academic Development (Ex: GED completion, Financial Aid assistance, Secondary enrollment assistance, Referrals for sponsorships for Workforce Training Programs, etc.)
Career Development (Ex: Job readiness assessments, Career Planning, Computer Skills Workshops, Resume assistance, Mock Interviews, Referrals to FSC Employment Partners, etc.)
Financial Literacy (Ex: Budgeting, Debt counseling, Banking/Saving, Investing, etc.)
Health & Wellness (Ex: Yoga, Zumba, Health & Nutrition workshops, Parenting, etc.)
Are you employed?
Please Select
Yes
No
Do you have transportation?
Please Select
Yes - I drive
Yes - I take the bus
Yes - I have someone that will bring me
No - I do not have a car
No - I do not have a license
No - I do not know how to take the bus
Do you have adequate/safe housing?
Please Select
Yes
No
I need assistance applying
Do you have health insurance?
Please Select
Yes
No
I need assistance applying
Do you have childcare?
Please Select
Yes
No
I do not have kids
Do you have adequate food and/or receive SNAP, EBT, TANF, etc.?
Please Select
Yes
No
I need assistance applying
FSC works with a variety of community partners and organizations. Please check the areas in which you may need support/referrals to other organizations for yourself and/or others IN YOUR HOUSEHOLD.
Workforce Development/Job Placement
Parenting Education and Support
Post Secondary Education (ex: getting a certification in areas such as healthcare, HVAC, Forklift, CDL, etc.)
Transportation (ex: learning how to ride a bus, assistance getting driver's fees reduced, tutoring for getting driver's license, etc.)
Health
Finances
Programs for child(ren) Ex: Mentoring groups, sports groups, etc.
Best Way to Connect With You
Please Select
Phone
Email
Text
No Preference
Referral Source
Please Select
Jaye Webb- FSC Director
Rita Scott- FSC Assistant Director
Katina Madison- FSC Admin Assistant
Chantea Neal- FSC Success Coach
Amanda Cook- FSC Success Coach
Carolyn Smith - FSC Success Coach
Grace Kelly - Lead FSC Success Coach
Melvinie Turner - FSC Success Coach
United Way
Learning Together Family Literacy
Nurse-Family Partnership
Regional Child Care Resources & Referral
Head Start/Early Head Start
Family Learning Center at Brentwood
NC Works
Recruitment Fair/Community Event
Triad Partner Coalition
Self/Online
Other
Submit
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