Getting to Know You Survey

Welcome! Please find below your survey for enrollment in a Women's Money Matters program. This survey will help us learn more about you and gain a better understanding of your financial needs. This information will help us match you with a compatible coach and give us a sense of the financial topics you are interested in to ensure that your experience is as relevant and useful to you as possible.

It will take approximately 15 minutes to answer the questions and we ask that you answer all questions. There are no right or wrong answers. All information is used solely by Women's Money Matters.

Please select the program day/time you wish to enroll in.

If you are joining a specific partner cohort, please select that program.

Financial Futures (adult program)

TUESDAYS (English/Virtual), evenings 6:30-8pm (English) *ET - Start date: 10/03/23WEDNESDAYS (Spanish/Virtual), evenings 6:30-8pm (Spanish) *ET - Start date: 10/11/23WEDNESDAYS (English/Virtual), evenings 6:30-8pm (English) *ET Start date: 10/25/23THURSDAYS (English/Virtual), evenings 6:00-8:30pm *ET (English) - Start date: 11/02/23MONDAYS (Spanish/Virtual), evenings 6:30-8pm *ET (Spanish) - Start date: 11/06/23MONDAYS (English/Virtual), evenings 6:30-8pm *ET (English) - Start date: 11/13/23*United Way of Greater New Bedford Virtual - Tuesdays, 6:30-8:00pm (English) Start date: 10/10/23*Community Action/Haverhill In-Person - Thursdays, 6:00-7:30 (English) Start date: 10/12/23

Life Launch (teen program)

Monday evenings 7:00pm-8:30pm (English) *ET - Start date: 10/16/23

Participant

Program ID

Program

Financial Futures CollectiveLife Launch Collective

Name of program partner:

Legal First Name

Legal Middle Name

Legal Last Name

Chosen or preferred name to be addressed?

We will be mailing out a graduation certificate and gift at the end of the program. Please be sure your mailing address is correct.

Phone

Email

Date of Birth

Primary Language

Other Language

If able to attend school, Please share the Level of Education Completed

Other Level of Education Completed

Enter the number of dependents you have for each age group. If you don't have dependent(s), enter 0 for all:

Infant - 5 years	14 - 18 years	18+ years	6 - 13 years

How would you describe your most significant financial challenge?

About You

List two words to describe yourself:

Any special interests or hobbies you’d like to share or any other details you would like us to consider when matching you with a coach?

Describe one thing you are especially proud of in life:

What is the most significant change you've faced in the last two years?

How do you hope this program will help you?

What days and times are best for you to meet with your coach? (Check all that apply)

Employment

Which best describes your current employment status?

Other Employment Status

If you are not currently employed, choose the option that best describe your situation

What kind of work do you do?

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Finances

Average Income

My average monthly income is $

per month.

Save Amount

I was able to save $

of it (enter zero if not applicable).

Other expense

Please indicate your current income sources (Check all that apply)

Other income source

Do you have debt?

YesNo

Other type of debt

Do you know what interest rate(s) you’re paying on your debt?

YesNo

How confident do you feel that you will be able to pay off all your debt?

In the past 3 months, have you: (Check all that apply)

	Always	Often	Sometimes	Rarely	Never	N/A
Used a budget
Spent less to stay within your budget
Paid your bills on time
Put money away for savings
Overdrawn an account
Paid more than the monthly minimum on debt(s)

Credit

Have you reviewed your credit report in the last year?

YesNo

I have not reviewed my credit report because:

Other reason for now reviewing credit report

What is your credit score range?

Which of these groupings contains three factors used to calculate a credit score?

Which factor counts the most in the calculation of a person’s credit score?

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Confidence

How confident do you feel in the following situations?

	Very Confident	Somewhat Confident	Unsure	Not Confident
Your ability to manage your money.
Ask a question about your account (if/when you have an account).
Contacting a credit bureau to discuss a mistake on your credit report (if/when you have one)?
Return an item of clothing that didn’t fit.
Inform a vendor if they charged you the wrong amount.
Discuss with a boss or a teacher something you feel is unfair or inaccurate.
Ask for a raise at a job.
Tell your friend that you don’t want to spend money going out to eat.

Please indicate which of the below topics you’re most interested in covering during the course of our financial education workshops. Select your top 3.

How to set financial goals and develop a plan to accomplish themHow to manage credit effectivelyHow to plan purchases (e.g. car, apartment, house)How to tackle debtHow to plan for financial security in older ageMore information about banking servicesMore information about insurance plans (e.g. car, renter's)More information about capital markets and stocksOther

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Thank You for Completing This Survey!

May we share this survey information with your coach?

YesNo

As a participant, you will receive one-on-one financial training from a money-management coach. In addition to attending a series of workshops with your coach, we ask that you and your coach have individual follow-up discussions -- either in person or over the phone. We request that you contact your coach at least 24 hours in advance, if possible, if you cannot make a previously scheduled workshop or meeting. Please sign below to indicate you understand and accept the responsibilities required of clients in this program.

Media Release Form

We hope to be able to celebrate the successes of our programs and participants with a wider audience, sharing photos and stories on social media and also with our supporters. Please let us know if you would be okay with allowing us to use your media to spread the word about our programs, by choosing one of the options below:

Release Form Choice

I hereby acknowledge and agree that my image and/or voice may be used and/or reproduced in connection with my participation in the Women's Money Matters program. I acknowledge and agree that meetings held virtually may be recorded and still photographs of the virtual meetings may be taken. I grant Women's Money Matters and its business partners all rights to the recording, taping, reproduction, copyright, display, distribution, redistribution, and transmission of my image and/or voice, any chat/text responses, and answers to any polling questions and waive all claims, including but not limited to privacy and compensation claims, I may have against Women's Money Matters and its business partners in connection with such use. I further waive all claims against Women's Money Matters or its business partners that I, my agents, heirs, or assigns may possess, now or in the future, in connection with such use including restrictions on waivers of future claims.

I do not agree to allow Women's Money Matters to use my image and/or voice in any capacity in connection with my participation in a Women's Money Matters program(s) and/or events.

Credit Score "Bucket" Release Form

We are always striving to provide the best possible programs to help our participants meet their long-term financial goals. One way we do this is by measuring the impact of our programs. Specifically, it is helpful for us to understand our participant credit scores and the impact our program has on them.

We respectfully ask your permission to collect your general Credit Score “buckets” (e.g., score of 500-550) and measure how it changes over time.

Our number one priority is privacy. This data (general Credit Score bucket and your personal identifiable information) will be held securely by Women’s Money Matters, and will not be shared in any non-anonymous capacity outside of the organization. Additionally, in no way will the data collection have any impact on your credit score. Let us know if you would be okay with us collecting your general credit score information for the purposes of our program quality measurement and offering additional support:

Release Form Choice

I hereby acknowledge and provide consent for Women’s Money Matters to access my credit files with the credit reporting agencies under the Fair Credit Reporting Act (FCRA) and to exchange the information about you to such national credit reporting agencies in order to to verify your identity using the information you provided (including but not limited to name, address, date of birth, email address, phone number) and receive a Credit Score “bucket” (not an exact credit score) for the purposes of program improvement, future support and coaching opportunities for graduates

I do not provide consent for Women’s Money Matter to access my credit files in any capacity.

If you selected Answer Choice #1, please enter the following information:

Legal First Name

Legal Last Name

Date of Birth (MM/DD/YYYY)

	Mondays	Tuesdays	Wednesdays	Thursdays	Fridays	Saturdays	Sundays
Morning
Afternoon
Evening

	Planning to attend	Considering	I don’t see myself there	I don’t have enough information
Four year college
Two year community college
Certificate/trade programs (e.g. coding, cosmetology, etc.)