Getting Ahead: Fall 2023
Student Application
Personal Information
Name
*
First Name
Last Name
Address
*
Street Address
Apartment/Unit Number
City
State
Zip Code
Preferred Phone
*
-
Area Code
Phone Number
Email
*
example@example.com
Date of Birth
*
/
Month
/
Day
Year
DOB
Family Composition
Do you have a spouse?
*
Yes
No
Spouse Name
First Name
Last Name
Spouse Phone
-
Area Code
Phone Number
Do you and spouse reside in same home?
Yes
No
Spouse Address (if different from applicant)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have children?
*
Yes
No
Childcare:
I do not need childcare for my child/children to attend class.
I do need assistance with childcare for child/children to attend class.
Child #1 Name
Child #1 Age
Child # 1 resides in home with applicant?
Yes
No
Child # 2 Name
Child # 2 Age
Child # 2 resides in home with applicant?
Yes
No
Child #3 Name
Child #3 Age
Child # 3 resides in home with applicant?
Yes
No
Child #4 Name
Child #4 Age
Child # 4 resides in home with applicant?
Yes
No
Child #5 Name
Child #5 Age
Child # 5 resides in home with applicant?
Yes
No
Child #6 Name
Child #6 Age
Child #6 resides in home with applicant?
Yes
No
Child #7 Name
Child #7 Age
Child #7 resides in home with applicant?
Yes
No
Education History
Do you have a high school diploma or GED?
*
Yes
No
Highest grade completed:
*
Please Select
1st - 6th grade
7th - 8th grade
10th grade
11th - 12th (non graduating)
Do you have a college degree?
*
Yes
No
Highest degree attained:
*
Please Select
Associate
Bachelor
Master
PhD
Are you currently enrolled in an college or university or any other educational program?
*
Yes
No
Name of school or program currently enrolled:
Anticipated graduation date:
Employment
Are you currently employed?
*
Yes
No
Employer Name
Job Title
Length of Employment
Do you have a resume?
*
Yes
No
I would like assistance creating my resume.
Yes
No
Attach resume here
Browse Files
Cancel
of
Income & Resources
Source of income (check all that apply):
*
Employed/wages
Unemployment
Social Security
TANF
Child Support
Food Stamps
Other
Total income from all sources checked:
Do you have reliable transportation?
*
Yes
No
I will need transportation to/from Getting Ahead classes each week.
Yes
No
May change week to week
Do you have health insurance?
*
Yes
No
Do you have dental insurance?
*
Yes
No
Do you have vision insurance?
*
Yes
No
Sensitive Information
Are you currently on probation or parole?
*
Yes
No
Do you have any felony convictions on your record?
*
Yes
No
Have you ever been evicted from a public housing program?
*
Yes
No
What areas are you experiencing difficulties?
*
Employment
Transportation
Training/education
Budgeting
Housing
Substance Abuse/Addiction
Dental issues
Health issues
Vision Issues
Legal Issues
Other
Housekeeping
I was referred to Shawnee Bridges:
*
Yes
No
Who or what agency referred you?
Select course schedule and start date:
*
October 10th - January 30th - this course meets every Tuesday 5:30 pm - 8:30 pm
October 12th - January 25th - this course meets every Thursday 1:00 pm - 4:00 pm
Referred by (name of person or agency):
I confirm the following are true:
*
I am not in a major crisis; I am fairly stable.
I will commit to attend 16 classes, meeting once weekly for up to three hours each week.
I give permission for Bridges staff to speak to referring entities about my life situation.
Shawnee Bridges may use my photo/video for marketing purposes:
*
Yes
No
Signature
Should be Empty: