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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
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State
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AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP/Postal Code
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Email Address
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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
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
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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
9.
Are you pregnant?
Yes
No
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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
No
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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.)
English
Arabic
Bosnian
Burmese
Chin
French
Karen
Karen Ni
Kirundi
Korean
Krahn
Russian
Somali
Swahili
Vietnamese
None
Other
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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
No
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
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.)
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
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)
24.
How did you hear about the program?