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? (Required.)

Tuesdays, 1-2:30pm

Thursdays, 6-7:30pm

I am available for either class

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2. Contact Information (Required.)

Name *

Address *

Address 2

City *

State *

ZIP/Postal Code *

Email Address *

Phone Number *

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3. County (Required.)

Fayette

Nicholas

Harrison

Bourbon

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4. Housing Type (Required.)

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 (Required.)

Female

Male

Other

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6. Date of Birth (Required.)

Date / Time

Date

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7. Race (Required.)

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 (Required.)

Hispanic

Non-Hispanic

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9. Are you pregnant?

Yes

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10. Employment Status (Required.)

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 (Required.)

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? (Required.)

Yes

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13. Military Status (Required.)

Never Served

Active Military

Veteran

Retired Military

National Guard

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14. Marital Status (Required.)

Divorced

Married

Separated

Single

Widowed

Other

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15. Disability Status (Required.)

Not Disabled

Disabled

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16. Preferred Language (Required.)

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17. English Proficiency (Required.)

Native Speaker

Fluent

American Sign Language (ASL)

Basic Proficiency

Not Proficient

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18. Do you have health insurance? (Required.)

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. (Required.)

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? (Required.)

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* 2. Contact Information (Required.)

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* 3. County (Required.)

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* 4. Housing Type (Required.)

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* 5. Gender (Required.)

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* 6. Date of Birth (Required.)

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* 7. Race (Required.)

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* 8. Ethnicity (Required.)

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* 9. Are you pregnant?

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* 10. Employment Status (Required.)

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* 11. Highest Level of Education Completed (Required.)

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

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* 13. Military Status (Required.)

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* 14. Marital Status (Required.)

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* 15. Disability Status (Required.)

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* 16. Preferred Language (Required.)

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* 17. English Proficiency (Required.)

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* 18. Do you have health insurance? (Required.)

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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. (Required.)

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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?

1. Which virtual program would you like to attend? (Required.)

2. Contact Information (Required.)

3. County (Required.)

4. Housing Type (Required.)

5. Gender (Required.)

6. Date of Birth (Required.)

7. Race (Required.)

8. Ethnicity (Required.)

9. Are you pregnant?

10. Employment Status (Required.)

11. Highest Level of Education Completed (Required.)

12. Are you currently enrolled in school or an education program? (Required.)

13. Military Status (Required.)

14. Marital Status (Required.)

15. Disability Status (Required.)

16. Preferred Language (Required.)

17. English Proficiency (Required.)

18. Do you have health insurance? (Required.)

19. If yes, health insurance type?

20. Health Insurance Provider

21. Member ID

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. (Required.)

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

24. How did you hear about the program?