Register for AARP Work for Yourself@50+ Online January 25, 2019
If you require accommodations to participate in this class, please contact Jean Dempster at 621-3434 or dempster@maine.edu

​Thank you for providing the following information. Your name and contact information will not be shared. Aggregate data is used for the pu​rposes of reporting to our funders and measuring the success of our programs.

​All fields are required on the registration form. Please contact ​Jean Dempster at 621-3434 or dempster@maine.edu if you prefer a paper copy or have any questions​. If you have taken a class with NVME recently, contact the trainer. Your registration information may already be on file.​

​​You may be contacted in the future to provide feedback on your experience with NVME.​

Name - First *
Your answer
Name - Middle
Your answer
Name - Last *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Email *
Your answer
Phone number *
Your answer
Alternate phone number
Your answer
How did you hear about us? *
Your answer
Sign me up for the email news about NVME programs. *
Required
Gender
I am of Franco-American heritage.
Do you consider yourself Hispanic or Latino?
In addition, check one or more of the following racial categories to describe yourself- *
Required
Work Status *
Required
I have a disability that limits my work *
Required
I receive SSI, SSDI, or veterans disability? *
Required
I am a veteran, active duty military or reservist *
Required
I receive unemployment insurance (UI)? *
Required
I am looking for work *
Required
Education Information *
Required
Are you currently enrolled in school? *
Required
If you are currently a student, what kind of program are you enrollled in?
Major field of study?
Your answer
Are you a University of Maine Augusta student? *
Number of people in your household including you *
Your answer
Total yearly Income for your household (from all sources) *
Your answer
Health Insurance coverage (choose one) *
Are you the Head of Household? *
Are you a single parent? *
My household receives food stamps. *
My household receives TANF. *
I have savings. *
I have retirement savings? *
Languages Spoken *
Required
Would you like to sign up for regular Work for Yourself@50+ emails? *
Have you ever been self employed? *
Has you previously attended entrepreneurship classes? *
Next
Never submit passwords through Google Forms.
This form was created inside of University of Maine System. Report Abuse - Terms of Service