YWCA Greater Lafayette STRIVE Application
This application must be completed as part of enrollment in YWCA Greater Lafayette's STRIVE program. If you need assistance filling out this form, please email empowerment@ywcagreaterlafayette.org or call 765-742-0075.

Please visit www.ywcalafayette.org/strive for more information.

After completing the application, please watch for an email with further instructions.
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Email *
What is your first name? *
What is your last name? *
Please indicate which STRIVE program you are applying for. Please note, afternoon sessions are currently suspended. *
What are your pronouns? *
What is your phone number?
What is your county of residence? *
What is your date of birth? *
What is your age? *
Please select the gender you most closely identify with: *
Do you identify as transgender?
Clear selection
Please select the race of ethnicity that you most closely identify with: *
Where did you hear about this program? *
What if your level of education? *
What is your current employment status? *
If employed, please list your employer:
How many people live in your home? *
What is your annual household income? (Write '0' if there are no employed adults in the home) *
What is your current annual salary? (Write '0' if you are currently not employed) *
How many minor children do you have? *
Do you have volunteer experience? *
Have you ever been a victim of a crime? (burglary, theft, assault/battery, sexual assault, rape, neglect, abuse, etc.) *
Have you ever been a victim of sexual assault? *
Have you ever been a victim of domestic violence? *
Have you ever experienced bullying? *
Do you have access to reliable internet? *
Do you have access to a laptop or desktop computer? *
Do you have access to a smart device? (tablet, smart phone, etc.)
Clear selection
Do you have reliable transportation? *
Are you authorized to work in the United States? *
How did you feel about school (elementary, middle, high school)? Check all that apply. *
How would you rate your digital skills? *
Were you referred to STRIVE by a business or organization? If so, please share the name of the referral source here. (ie. Community Corrections, FSSA, LTHC, etc.) *
I understand that this application is for admission only for the term indicated. I agree that I am bound by YWCA Greater Lafayette’s regulations concerning application deadlines and admission requirements. I understand that applying for this program does not guarantee acceptance. I certify that this information is complete and accurate. I understand that making false or fraudulent statements within this application or residency statement will result in denial of admission, and invalidation of credit or certificates earned. If admitted, I agree to abide by the policies of STRIVE and the rules and regulations of YWCA Greater Lafayette. Should any information change prior to my entry into STRIVE, I will notify YWCA Greater Lafayette. *
Please type your name to indicate you agree to being contacted about your application by YWCA Greater Lafayette Empowerment Services staff. Instructions for accessing STRIVE materials and live sessions will be sent to the email you have provided. *
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