community Resources Workshop
____Monday, April 9, 2012 (6:00 p.m. to 9:00 p.m.)
____Monday, June 18, 2012 (9:00 a.m. to 12 p.m.)
____ Monday, September 10, 2012 (6:00 pm - 9:00 pm)
____ Monday, November 19, 2012 (6:00 pm - 9:00 pm)
Classes meet at: Housing Assistance Corporation
460 West Main Street
Hyannis, MA
This is a one evening class that will help participants learn about resources within the community to live more economically. Discussion of services available at your local bank, energy audits, and other ways to save money. You will learn about all these things and more!
Space is limited to 20 participants. Please complete the registration form. Keep the first page for your reminder. Return all other pages to:
Cheryl Kramer-HCEC
Housing Assistance Corporation
460 West Main Street
Hyannis, MA02601
Contact Cheryl at 508-771-5400 x287 or f you have any questions.
Please keep this page to remind yourself of the class. You will receive a confirmation letter if you have registered at least one week prior to the class.
Community resources workshop
____Monday, April 9, 2012 (6:00 p.m. to 9:00 p.m.)
____Monday, June 18, 2012 (9:00 a.m. to 12 noon)
____ Monday, September 10, 2012 (6:00 pm - 9:00 pm)
____ Monday, November 19, 2012 (6:00 pm - 9:00 pm)
Registration reserves your seat. Space is limited.
Please return this and all following pages.
Please Print
Date______Monthly Rent $______
Name______
Street Address______
Town______Zip Code______
Mailing Address______
Home Phone______
Cell Phone______
Work Phone______
Email______
Referred By______
Are you a FSS Participant? (Please circle) Yes No
Are you a HOME BASE Participant? (Please circle) Yes No
HAC receives funds from various sources for counseling services, so we are required to collect certain data. We also use the information we collect to evaluate our workshops and learn more about the people we are serving. The information collected from this form is completely confidential.
Name: / Name:1. Age:
_____ 20-30 years
_____ 31-40 years
_____ 41-50 years
_____ 51-60 years
_____ 60+ years / 1. Age:
_____ 20-30 years
_____ 31-40 years
_____ 41-50 years
_____ 51-60 years
_____ 60+ years
2. Gender: Male____ Female _____
3. Veteran? Yes_____ No _____
4. Disabled? Yes_____ No_____
5. Are you the Head of the Household?
Yes_____ No _____ / 2. Gender: Male____ Female _____
3. Veteran? Yes_____ No _____
4. Disabled? Yes_____ No_____
5. Are you the Head of the Household?
Yes_____ No _____
7. Marital Status
____Choose Not to Respond
____ Married
____Separated
____Single
____Unknown
____Widowed / 7. Marital Status
____Choose Not to Respond
____ Married
____Separated
____Single
____Unknown
____Widowed
11. Highest Level of Education Completed:
______Less than high school graduate
______High School Diploma/ GED
______2-year college
______Bachelor’s Degree
______GraduateSchool/ Post
Secondary Degree / 11. Highest Level of Education Completed:
______Less than high school graduate
______High School Diploma/ GED
______2-year college
______Bachelor’s Degree
______GraduateSchool/ Post
Secondary Degree
9. Have your parents or grandparents ever owned a home in the U.S.?
Yes _____ No _____ / 9. Have your parents or grandparents ever owned a home in the U.S.?
Yes _____ No _____
10. Where were you born?
_____ U.S.
_____ U.S. Territory (e.g., Puerto Rico)
_____ Other Country: ______/ 10. Where were you born?
_____ U.S.
_____ U.S. Territory (e.g., Puerto Rico)
_____ Other Country: ______
6. Ethnicity:
______Hispanic/ Latino
______Non Hispanic/ Latino
* For Census 2000, there are two categories for ethnicity: Hispanic or Latino and not Hispanic or Latino. The federal government considers race and Hispanic origins to be two separate and distinct concepts. Hispanics and Latinos may be of any race. (Source: / 6. Ethnicity:
______Hispanic/ Latino
______Non Hispanic/ Latino
* For Census 2000, there are two categories for ethnicity: Hispanic or Latino and not Hispanic or Latino. The federal government considers race and Hispanic origins to be two separate and distinct concepts. Hispanics and Latinos may be of any race. (Source:
8. Race: (please select one)
Single Race Categories
_____ American Indian or Alaskan Native
_____ Asian
_____ Black or African American
_____ Native Hawaiian or Other Pacific
Islander
_____ White
Multi-Race Categories
_____ American Indian or Alaskan Native
and White
_____ Asian and White
_____ Black or African American and
White
_____ American Indian or Alaskan Native
and Black or African American
_____ Other Multiple Race / 8. Race: (please select one)
Single Race Categories
_____ American Indian or Alaskan Native
_____ Asian
_____ Black or African American
_____ Native Hawaiian or Other Pacific
Islander
_____ White
Multi-Race Categories
_____ American Indian or Alaskan Native
and White
_____ Asian and White
_____ Black or African American and
White
_____ American Indian or Alaskan Native
and Black or African American
_____ Other Multiple Race
12. Have you seen a copy of your credit report in the last year?
Yes ______No ______/ 12. Have you seen a copy of your credit report in the last year?
Yes ______No ______
13. Do you know your credit score?
Yes ______No ______/ 13. Do you know your credit score?
Yes ______No ______
Household Information
14. Household Size: Number of Adults: ______Number of Children ______