Getting Ahead Investigator Application

Name

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Today's Date: *

MM

DD

YYYY

Phone: *

(###)

###

####

Please check the following if you agree:

I understand that I must complete an interview with Getting Ahead staff. Completion of this application does not guarantee acceptance into the program.

I understand that if I am accepted into the program, I must attend all 18 sessions. Participants are allotted two missed sessions.

I understand that if I am accepted into this program, I am expected to actively participate in each workshop session. This will include but is not limited to, adding to the discussions, sharing experiences, and being an active listener.

I verify that I am a Marathon County resident.

I verify that I am not a convicted sex offender.

Name:

First Name

Last Name

Phone:

(###)

###

####

Gender: *

Female

Male

Other

Prefer not to say

Race/Ethnicity: *

Select all that apply

American Indian or Alaskan Native

Asian

Black or African American

Hispanic/Latino

Native Hawaiian or Pacific Islander

White

Marital Status: *

Never Married

Married

Divorced

Widowed

Domestic Partner

Separated

Other

Highest Level of Education: *

Incomplete High School

High School

GED

Some College

Associate's Degree

Bachelor's Degree

Master's Degree

Employment: *

Part Time

Full Time

Seasonal/Temp

Retired

Disabled

Unemployed

Sources of Income: *

Select all that apply

Employment

SSI

SSDI

Social Security Retirement

Child Support

Alimony

Other

No Income

Housing: *

Own

Rent

Doubled Up

Transitional

Homeless

Other

Are You Currently Experiencing Any of the Below Situations? *

Select all that apply Does not determine eligibility

I am unhoused.

I am fleeing domestic violence.

I am struggling with alcohol and/or drug abuse and not receiving help.

I am struggling with my mental health and not receiving help.

None of the above situations apply to me.

Please Place a Check Mark Next to the Areas You Are Experiencing Difficulties: *

Finding Employment

Maintaining Employment

Education/Training

Legal Problems

Budgeting

Parenting

Housing

Friendships/Relationships

Isolation

Drugs/Alcohol

Childcare

Healthcare Costs

Physical Health

Mental Health

None of the above

Do you need Childcare support to attend the Program? *

Yes

No

Do you need transportation assistance to attend the Program? *

Yes

No

Please Place a Check Mark Next to All Public Assistance/Services Your Family Receives: *

TANF/W-2

Food Stamps

FSET

Subsidized Housing/Section 8

Vocational Rehab

Childcare Assistance

Headstart

BadgerCare Plus/Medicaid

Family Care/IRIS

WIC

Community Support Program

Rent Assistance

Energy Assistance

Other

None of the above