Financial Fitness Registration

Welcome! Please complete the form below to register for the Financial Fitness Program.

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* 1. Which virtual program would you like to attend?

Tuesdays, 1-2:30pm

Thursdays, 6-7:30pm

I am available for either class

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* 2. Contact Information

Name *

Address *

Address 2

City *

State *

ZIP/Postal Code *

Email Address *

Phone Number *

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* 3. County

Fayette

Nicholas

Harrison

Bourbon

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* 4. Housing Type

Own

Rent/Non-Subsidized

Rent/Subsidized

Emergency Shelter

HUD Supported Unit (does not own or rent)

Transitional Housing

Temporary Shelter

Homeless

Other Residence (does not own or pay rent)

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* 5. Gender

Female

Male

Other

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* 6. Date of Birth

Date / Time

Date

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* 7. Race

African-American

African-American & American Indian/Alaskan Native

African-American & White

American Indian/Alaskan Native

Asian

Asian & White

Multi-Racial

Native Hawaiian & Other Pacific Islander

White

White & American Indian/Alaskan Native

Other

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* 8. Ethnicity

Hispanic

Non-Hispanic

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* 9. Are you pregnant?

Yes

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* 10. Employment Status

Employed Full-Time

Employed Part-Time

Migrant Seasonal Farm Worker

Retired

Unemployed (Short-Term, 6 months or less)

Unemployed (Long-Term, more than 6 months)

Unemployed (Not in labor force)

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* 11. Highest Level of Education Completed

Pre-School

Early Head Start

Head Start

Grades 0-8

Grades 9-12

High School Graduate

Equivalency Diploma (GED)

12 grade + Some Post-Secondary

2 or 4 years College

Advanced/Post-Secondary Degree

Technical/Trade School

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* 12. Are you currently enrolled in school or an education program?

Yes

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* 13. Military Status

Never Served

Active Military

Veteran

Retired Military

National Guard

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* 14. Marital Status

Divorced

Married

Separated

Single

Widowed

Other

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* 15. Disability Status

Not Disabled

Disabled

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* 16. Preferred Language

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* 17. English Proficiency

Native Speaker

Fluent

American Sign Language (ASL)

Basic Proficiency

Not Proficient

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* 18. Do you have health insurance?

Yes

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* 19. If yes, health insurance type?

Direct-Purchase

Employment Based

Medicaid

Medicare

Military Health Care

State Children's Health Insurance Program

State Health Insurance for Adults

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* 20. Health Insurance Provider

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* 21. Member ID

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* 22. How much money do YOU personally earn yearly? Please choose the total amount of money you earn - do not subtract the amount you pay in taxes or any deductions listed on your tax return.

Under $10,000

Between $10,999 and $19,999

Between $20,000 and $29,999

Between $30,000 and $39,999

Between $40,000 and $49,999

Between $50,000 and $59,999

$60,000 or more

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* 23. What are your financial obstacles? (Choose all that apply)

Excessive spending

An inability to budget

Difficulty paying bills

A struggle to save

Student loan debt

Credit card debt

Utility debt

Medical bill debt

Poor spending habits

Poor credit score

Living paycheck-to-paycheck

Limited or non-existent understanding of investing

Limited/no retirement plan

Poor money management (regardless of salary)

Difficulty paying rent/mortgage

Other (please specify)

Financial Fitness Registration

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* 1. Which virtual program would you like to attend?

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* 2. Contact Information

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* 3. County

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* 4. Housing Type

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* 5. Gender

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* 6. Date of Birth

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* 7. Race

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* 8. Ethnicity

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* 9. Are you pregnant?

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* 10. Employment Status

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* 11. Highest Level of Education Completed

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* 12. Are you currently enrolled in school or an education program?

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* 13. Military Status

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* 14. Marital Status

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* 15. Disability Status

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* 16. Preferred Language

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* 17. English Proficiency

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* 18. Do you have health insurance?

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* 19. If yes, health insurance type?

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* 20. Health Insurance Provider

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* 21. Member ID

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* 22. How much money do YOU personally earn yearly? Please choose the total amount of money you earn - do not subtract the amount you pay in taxes or any deductions listed on your tax return.

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* 23. What are your financial obstacles? (Choose all that apply)

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* 24. How did you hear about the program?