Participant Registration Sheet
Financial Education Boot Camp
Please select your preferred class format? (Please Note: Refer to class schedule on www.mcfac.net for a full list of upcoming classes. In person class sessions vary by location and are subject to availability.)
Online/Zoom
In Person
Name
*
Boot Camp Name/Number (ex: MCFAC0001)
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-MAIL
*
example@example.com
TELEPHONE NUMBER
*
Format: (000) 000-0000.
Gender
*
Male
Female
Race/Ethnicity
*
Black or African American
While
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Hispanic or Latino
Have you or anyone in your household served or is currently serving in the United States Military?
*
Yes
No
What is your current method of banking?
*
Bank
Credit Union
I do not have a bank account
What banking product(s) do you currently utilize?
Checking account
Savings Account
Loans
None
What best describes you main sources of income?
*
Wages
SSI/SSDI
Retirement
Self Employed
Other
Which of the following best describes your industry of employment?
Please Select
Education
Farming/ Ag
Finance
Manufacturing
Medical/ Healthcare
Retail
Social Services
Transportation
Government
Other
What is your income range?
*
Please Select
$0-$5,000
$5,000-$10,000
$10,000-$25,000
$25,000-$50,000
$50,000- and over
Which of the following best describes your housing?
*
Rent
Own
Need to Rehab your home
Wanting to purchase
Have you ever reviewed your credit report?
*
Please Select
Yes
No
If so, when is the last time you reviewed your credit report?
How did you hear about this class?
*
It is important that I learn:
*
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Photo, Video, Audio and Information Release Form
I authorize the Mississippi Community Financial Access Coalition (MCFAC herein) and/or its partners to use my photograph, interview, video recording, likeness and/or personal story for promotional, marketing, advertising, or publicity purposes of MCFAC and its assigns or transferees. I also permit MCFAC to use, reproduce, exhibit, display, broadcast and/or make available to the general public via the internet, television, radio, printed materials and/or other medium. I further agree that any or all of the materials generated may be used, in any form, as part of any future publications, brochures, or other printed materials used to promote MCFAC. I release and fully discharge MCFAC, its employees or assigns from any liability from use of the aforementioned likeness or information. Further, such use shall be with demand for payment, royalties, fees or other compensation.
I Agree
Signature
*
Date
-
Month
-
Day
Year
Date
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