Skip to content
FWP Registration MAY 2023- Cohort 2
1.
First and Last Name
2.
D/O/B:
3.
Email address:
4.
Cell Phone Number [ex. (area code)-123-4567]
5.
Do you live in Detroit?
Yes
No
6.
Address
Address
Address 2
City/Town
State/Province
ZIP/Postal Code
Country
7.
How many family members, including yourself, do you currently live with?
8.
How would you describe your ethnic group? (select all that apply)
White or Caucasian
Black or African American
Hispanic or Latino
Asian or Asian American
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Biracial/ Multiracial
9.
Please specify your gender
Female
Male
Non binary
Other
Prefer not to answer
10.
What is your marital status?
Married
Common law
Separated
Divorced
Single
Widowed
11.
What is the highest level of school that you have finished?
Completed 4 years of college or more.
Completed 2 years of college.
Completed some college.
High school diploma or GED
Less than a high school degree
12.
What is your household income?
Under $15,000
Between $15,000 and $29,999
Between $30,000 and $49,999
Between $50,000 and $74,999
Between $75,000 and $99,999
Between $100,000 and $150,000
Over $150,000
13.
What language are you most comfortable speaking?
14.
What is your current work situation?
Employed (fulltime)
Employed (parttime)
Contract/ Seasonal/ Temporary
Unemployed
Self employed.
Retired
15.
Do you participate in any of the following programs? [Select all that apply]
SNAP/Food Benefits (Supplemental Nutrition Assistance Program)
FAP (Food Assistance Program)
FIP/TANF/AFDC/Cash Benefits
WIC
Head start/Early Head start
Energy Assistance
Other
16.
How did you hear about the program?
Phone (via Text or Call)
Social Media
Brillian Detroit
Referral
Other
17.
Select your preferred Brilliant Detroit Neighborhood Hub
I am not affiliated with a Brilliant Detroit Hub
Spring wells Brilliant Site: 9104 Rathbone, Detroit, MI 48209
Southwest Site: 5675 Larkins St, Detroit, MI 48210
Osborn Brilliant Site: 13800 Eastburn Street, Detroit, MI 48205
Morningside Brilliant Site: 5048 Balfour Rd., Detroit MI 48224
Martin Park Brilliant Site: 16587 La Salle Ave Detroit, MI 48221
Littlefield - 12789 Indiana Ave, Detroit, MI 48238
Fitzgerald Brilliant Site: 16919 Prairie, Detroit, MI 48221
Dexter-Linwood Brilliant Site: 2634 Webb, Detroit, MI 48206
Cody Rouge Brilliant Site: 7425 Fielding, Detroit, MI 48228
Chandler Park - 5312 Newport, Detroit, MI 48213
Central Detroit Brilliant Site: 803 Hazelwood, Detroit, MI 48202
Brightmoor Brilliant Site: 15509 Heyden, Detroit, MI 48223
18.
Please select the session you would like to attend.
Tuesday afternoon 4:00pm
Wednesday morning 11:00am
Wednesday afternoon 4:00pm
19.
Have you participated in this program before?
Yes
No
20.
Do you understand that an onboarding session is required before the program begins, in which you will visit for a quick intake of metrics (weight, blood pressure, receiving the curriculum, etc.) THIS SHOULD NOT TAKE MORE THAN 15-20 MINS.
Yes
No