Getting Ahead Class Participant Application

Getting Ahead Class Participant Application

A program of Cooperative Christian Ministries and Clinic
Getting Ahead classes help people move from financial and personal instability to a more hopeful future by examining 11 resources and developing a plan to successfully move forward. There are 14 weekly classes that last for 2 1/2 hours, once a week. Classes are held at various times of year in several locations. Once this application is received, you will be contacted by CCMC's Getting Ahead Coordinator to assign you to a specific class. You are required to attend all classes in order to graduate. Meals and incentives are provided at the conclusion of each class. For more information, contact Starla Bleifus, sbleifus@ccmchs.org or call 501-318-1153 x303.
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Gender

MaleFemale
Email
example@example.com
I was referred to Getting Ahead by:
Place of Employment:
Highest level of education:
Currently enrolled in this Education Program:
Please check all sources of income:

WagesSSIUnemploymentChild supportOther
Please check all that apply to you:

I have a check accountI have a savings accountI have reliable transportationI currently have a jobI have stable housing
Please rank your highest level of hope (1 = low to 10 = high)
Please check all agencies you are currently working with:

Head StartFood Stamps/SNAPFree/Reduced School Lunches, WICAcademic Financial AidAdult Education (GED)Other
Place a check next to the areas where you are experiencing difficulties:

EmploymentIsolationTransportationHousingTraining/EducationAlcohol/DrugsBudgetChildcare costsLegalHealthcare costsParentingMental healthOther
I certify that the following are true (check):

I am not in major crisis (untreated mental illness or drug/alcohol addiction, domestic violence situation, homeless); major crisis has been stabilizedI give permission for the CCMC staff to talk to my reference about my life situation, strengths, and barriers.I am willing to participate in every weekly class (approximately 2 1/2 hours, once a week)
By typing your name here, you are giving CCMC permission to use class work, photos and videos taken during this program, and conducting a background check for informational purposes.
Today's Date

MonthDayYear
This is an application for the Getting Ahead classes. It does not guarantee you will be accepted. Thank you for your interest and for taking the time to complete this application. Please click below to submit your application. You will be contacted soon.

Call 501-318-1153 x303 or email jmhart@ccmchs.org
FOR OFFICE USE ONLY:
Interview date scheduled
Should be Empty: