Breaking Free Application

Name*

Prefix First Middle Last

Birth Date*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone #*

Email*

Marital Status:*

Race*

African American
Caucasian
Hispanic
Two or more races
Asian
Native American
Other

How did you hear about this course?*

CCM Housing client
CCM Financial Assistance referral
Atrium employee
AYA House/Opportunity House

Do you have any physical limitations?*

If so, what are they?*

Do you have any dietary restrictions?*

If so, what are they?*

Spouse's Name:

Spouse's Birth Date

Will your spouse be attending with you?

Yes
No

How many children will be coming with you?

What is the name, age and relationship to you of Child 1?*

Birthdate of Child 1*

What is the name, age and relationship to you of Child 2?*

Birthdate of Child 2*

What is the name, age and relationship to you of Child 3?*

Birthdate of Child 3*

What is the name, age and relationship to you of Child 4?*

Birthdate of Child 4*

What is the name, age and relationship to you of Child 5?*

Birthdate of Child 5*

Do you have internet access at home?*

Yes
No

Do you have access to a computer or smart phone?*

Yes
No

What is the best way to communicate with you?*

Phone
Email

Which location would you prefer to meet with your community partner coach?*

Concord
Kannapolis

Educational Information

Did you complete high school?*

Yes
No

What is the highest grade level completed?

Are you currently enrolled in school?*

Yes
No

What School are your attending?

Are you pursuing further education?*

Yes
No

What further education are you pursuing?

When do you start?

When is your anticipated graduation date?

Are you taking classes this term?

Yes
No

Why are you not taking classes this term?

Employment Information

Are you currently employed?*

Yes
No

Where are you employed?

Employer Location:

City State

How long have you worked at this employer?

What is your monthly take-home income?*

What are your work hours?

Have you worked in the last 6 months?

Yes
No

What is the date and location of your last employment?

Please check any other sources of income:*

Unemployment
Child Support
TANF (WorkFirst)
SSI/SSDI
Other
None of the Above

How much unemployment do you receive?*

How much child support do you receive?*

How much TANF do you receive?*

How much SSI/SSDI do you receive?*

How much other income sources do you receive?*

Please check all public assistance/services your family currently receives:

TANF (WorkFirst)
Head Start
Utilities/Energy Assistance
Food Stamps
WIC
Vocational Rehab
Childcare Assistance
Housing Assistance (SEC 8/Rental Assistance/Income Based Housing/Senior Housing
Free/Reduced School Lunch

Please check the following areas you are having difficulties or would like more information:*

Finding Employment
Education/Training
Housing
Maintaining Employment
Budgeting
Other

Please specify the other areas you would like more information*

Do you plan to pursue home ownership within the next year?*

Yes
No

Please upload your Drivers License or Picture ID*

Max. file size: 45 MB.

Does your uploaded Drivers License or Picture ID contain your current address?*

Yes
No

Please upload a utility bill or lease displaying your current address.*

Max. file size: 45 MB.

Consent*

I agree.

Please read carefully the following terms and conditions. By checking the box, you are giving your consent. By submitting this form, you are agreeing to complete and participate in all Breaking Free classes (5 sessions).

Initial*

Date

Thank you for your interest in our Breaking Free program!

Date

Name

This field is for validation purposes and should be left unchanged.