Reset Training Program Application

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number

Format: (000) 000-0000.

E-mail

example@example.com

Are you the head of your household?

What is your ethnicity?

What is your race?

What is your gender?

List any school-aged children and current grade level:
First Name*   Last Name*      Grade*
First Name   Last Name      Grade
First Name   Last Name      Grade
First Name   Last Name      Grade
First Name   Last Name      Grade
First Name   Last Name      Grade
First Name   Last Name      Grade
First Name   Last Name      Grade
First Name   Last Name      Grade
First Name   Last Name      Grade

Do you receive SNAP or TANF Benefits

What is your employment status?

Other

Are you currently enrolled in school or taking courses?

Other

What is your highest level of education?

How did you learn of this opportunity?

What area of your life do you need to reset?

How will the Reset Training Program help you?

How will you attend/join the in person training program, scheduled for the 2nd and 4th Tuesdays of each month? What access to transportation do you have?

How will you attend/join the virtual coaching session? What access to the internet and device do you have?

What allergies might you have? What medications are you taking?

What mental well being therapists or counselor might you be seeing and for what reason?

Please list the name(s) of emergency contact(s):

First Name*   Last Name*   Street Address*      City*   State*   Zip*   Area Code*   Phone Number*

First Name   Last Name   Street Address   Address Line 2   City   State   Zip   Area Code   Phone Number

First Name   Last Name   Street Address   Address Line 2   City   State   Zip   Area Code   Phone Number

I understand this course will be held IN-PERSON from 7:00-8:30PM EST every 2nd and 4th Tuesdays during months (October - November- December) to be announced.

I understand that after the 12-week program completion, I am required to submit and electronic bi-weekly check in form to communicate your further progress towards reaching your goals. Due dates will be determined by the program coordinator.

I understand the virtual coaching sessions will be scheduled according to a schedule that is agreeable for both myself and the coach (1 hour per week)?

If you are accepted into the program are you willing to attend each in person training session and each virtual coaching session?

I agree that the answers provided above are true and correct to the best of my knowledge. I understand the terms of the Reset Training Program.