YWCADE- YW Strive Registration

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Training is at 709 N Madison Street (HLMC) Tuesday 01/16/2024 thru Tuesday 2/20/2024

Registration information is Confidential

Email *

YW Strive

Full Name *

Preferred Name *

Pronouns

Gender *

Race *

Ethnicity

Hispanic

Not Nispanic

Date of Birth *

YYYY

Street Address *

City *

State *

Specify State or answer N/A if your state is listed in previous question *

Zip Code *

Phone Number with area code *

Marital Status *

Do you need babysitting to attend this training? *

Yes

Maybe

How many children do you require baby sitting services for? *

How old is the child or children? Please include all ages. *

Education History *

Are you currently employed? *

Name of Employer or answer Unemployed *

Do you have a Criminal Background? Your answer will not exclude you from participating. *

Yes

Individual Annual Income *

Income Sources *

Current Head of Household *

Number in Household *

Access to internet *

Yes

Access to laptop or tablet *

Yes

Do you consent to pictures or video of your image during training? *

Yes

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