Name

First Name

Last Name

Phone

(###)

###

####

Do you identify as Black, Indigenous, or a Person of Color (BIPOC)? *

This program is specifically designed for people of color.

Yes

No

1. a) Please select the type of financial goal you are most committed to pursuing this year. *

While we understand that you may be pursing multiple financial goals, we'd like to know which goal is of highest priority for you.

Housing Goal (securing affordable rental, getting pre-approved for a mortgage, buying a home, etc)

Personal Finance Goal (paying down debt, increasing savings, etc.)

Business Goal (starting or expanding your own business)

4. Are you interested in individualized coaching to help you achieve your financial goals? *

The BIPOC Financial Empowerment Program will provide free 1:1 coaching with one of our coaches. Please select which coaching you are most interested in.

Housing/Homeownership Coaching with Ana Mejia, Windham & Windsor Housing Trust

Financial Coaching with Erika Dox-Martinez, Blissful Vida

Business Coaching with Rosalie Ennes, Portecua Consulting

I am not interested in 1:1 coaching

5. b) If you answered yes to the previous question, which statement(s) best describe what the outcome was

I reported it, someone followed up with me and the situation was resolved in a just manner

I reported it, someone followed up with me and the situation was NOT resolved in a just manner

I reported it and no one followed up with me about my report

I did NOT report it because I was able to resolve the manner to my satisfaction

I did NOT report it because I didn’t know how/who to report it to

I did NOT report it because I didn’t trust that anyone would do anything about it

I did NOT report it because I feared I would be subjected to retaliation

7. Do you have a good sense of how much money you make and how much you spend each month? *

Yes

No

9. Because of my money situation, I feel like I will never have the things I want in life *

This statement describes me:

Completely

Very well

Somewhat

Very little

Not at all

10. I am just getting by financially *

This statement describes me:

Completely

Very well

Somewhat

Very little

Not at all

11. I am concerned that the money I have or will save won’t last *

This statement describes me:

Completely

Very well

Somewhat

Very little

Not at all

12. I have money left over at the end of the month *

This statement applies to me:

Always

Often

Sometimes

Rarely

Never

13. My finances control my life *

This statement applies to me:

Always

Often

Sometimes

Rarely

Never

14. Can you commit to attend all scheduled workshops? *

We will prioritize applicants who can fully commit to the program. If you plan to miss 3 or more workshops please consider applying for a future year.

I can commit to attend all workshops

I have scheduling conflicts for 1 workshop date

I have scheduling conflicts for 2 workshop dates

I have scheduling conflicts for 3+ workshop dates