Registration for Getting Ahead
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Full Name
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Preferred Name *
Date of Birth
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DD
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YYYY
Full Address *
Email Address *
Phone Number *
Would you prefer to attend in person or a hybrid model where we meet mostly online, but in person once a month? *
What city/town/village in Huron County do you prefer to meet in? *
What day of the week & time of day work best for you? (Please click all that apply)
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Required
Emergency Contact Name & Phone Number
 *
Tell me a little about who lives in your household. Please list names, ages, and relationship.  *
Is there anything else about your family that we should know? 
 *
Who referred you to the Getting Ahead program?
 *
Are you employed? *
If you are employed, please share a little about your job. Who do you work for? What is your job title? How long have you worked there? *
What is your transportation situation? *
What is your highest level of education? *
Please check the areas where you are experiencing difficulties.
 *
Required
I certify that all of the following are true:
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Required
Do you have any barriers to participation? If so, please describe so that we can help support you. *
Photo/Video Release. If you are selected as one of our participants/investigators, do you authorize staff to use pictures and videos of yourself for promotion and inspiration to others? *
We will be serving light refreshments. If you have any food allergies, it is your responsibility to ask about ingredients. We are not responsible for any medical or allergic reactions you may have. Do you have any allergies we should be aware of?  *
When you sign this page, you agree to put forth your best effort to complete the program, participate in evaluation activities, and follow established group rules. Registration is accepted on a first come, first service basis. Please type your full name & date. *
If you have any further questions, please contact Janeen Bourlier at phone number 810-987-9337 EXT. 8801 or email JBourlier@DNEMichigan.org
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