Financial Education - Registration Form

ZOOM Financial Education - Registration Form

Note: ZOOM video conferencing will be used through June. Locations given are subject to change based on public health & safety needs.
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Gender*
Age*
Ethnicity*
Race*
Marital Status *
Education*
Primary Language*
Limited English *
Veteran*
Disabled*
Country of Origin*
Spouse Name

First NameMiddle NameLast Name
Education
Limited English
Country of Origin
Gender
Ethnicity
Race
Age
Date of Birth

MonthDayYear
Veteran
Disabled
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Length of Occupancy*
Rent or Own*
Housing Status *
Are you interested in obtaining information about City sponsored programs?*
Student*
Retired *
Phone Number*

Area CodePhone Number
Cell Phone*

Area CodePhone Number
E-mail*
Dependent Information:
Household Type *
Family Size*
Number of Adults*
Number of Children
Number of Other Dependents*
Males
Ages
Ethnicity
Race
Disabled
Females
Ages
Ethnicity
Race
Disabled
Income Source*
Employer/Benefit Type*
Combined Gross Monthly Income*
Combined Gross Annual Income *
TANF Benefits *
Insurance*
Savings Account*
Checking Account*
Do You Have Assets Over $10,000*
Have You filed Bankruptcy:*
Do You Owe Money for a Bounced Check*
Have you used a Payday Lender*
Balance Owed*
Are You In A Debt Repayment Plan*
Do You Have Delinquent Student Loans
Do you have any of the following:
Charge offs
Judgments
Collections
Medical Collection
Back Child Support
Workshop Dates*
If the workshop is scheduled for 3 days you must attend all 3 days in order to complete the class and obtain the certificate
How did you hear about the workshops? *
Organization/Individual who referred you?*
Should be Empty:

ZOOM Financial Education - Registration Form

Dependent Information: