Mi Casa's Financial Wellness Program!
Hidden
Contact ID (Hidden)
Program Account ID (Hidden)
Household Account ID (Hidden)
Opportunity ID (Hidden)
Participation Type
Financial Wellness Program (ENG)
Financial Wellness Program (SPA)
Please select the Financial Wellness sessions you would like to attend (select all that apply):
Seleccione las sesiones de salud financiera a las que le gustaría asistir (seleccione todas las que correspondan):
Part 1: Financial Wellness Program 10/3, 17/3, 24/3, 31/3, 7/4
Part 2: Financial Wellness Program 14/4, 21/4, 28/4
Parte I: Salud Financiera 5/3, 12/3, 19/3, 26/3, 2/4
Parte II: Salud Financiera 16/4, 23/4, 30/4, 7/5, 14/5
Personal Information
First Name /
Premier Nombre
MI /
Segundo Nombre
Last Name /
Apellido
Date of Birth /
Fecha de Nacimiento
Street Address /
Número y Calle
State /
Estado
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
City /
City
Please select...
Aguilar
Akron
Alamosa
Alma
Antonito
Arriba
Arvada
Aspen
Ault
Aurora
Avon
Basalt
Bayfield
Bennett
Berthoud
Bethune
Black Hawk
Blanca
Blue River
Bonanza
Boone
Boulder
Bow Mar
Branson
Breckenridge
Brighton
Brookside
Broomfield
Brush
Buena Vista
Burlington
Calhan
Campo
Canon City
Carbondale
Castle Pines North
Castle Rock
Cedaredge
Centennial
Center
Central City
Cheraw
Cherry Hills Village
Cheyenne Wells
Coal Creek
Cokedale
Collbran
Colorado Springs
Columbine Valley
Commerce City
Cortez
Craig
Crawford
Creede
Crested Butte
Crestone
Cripple Creek
Crook
Crowley
Dacono
De Beque
Deer Trail
Del Norte
Delta
Denver
Dillon
Dinosaur
Dolores
Dove Creek
Durango
Eads
Eagle
Eaton
Eckley
Edgewater
Elizabeth
Empire
Englewood
Erie
Estes Park
Evans
Fairplay
Federal Heights
Firestone
Flagler
Fleming
Florence
Fort Collins
Fort Lupton
Fort Morgan
Fountain
Fowler
Foxfield
Fraser
Frederick
Frisco
Fruita
Garden City
Genoa
Georgetown
Gilcrest
Glendale
Glenwood Springs
Golden
Granada
Granby
Grand Junction
Grand Lake
Greeley
Green Mountain Falls
Greenwood Village
Grover
Gunnison
Gypsum
Hartman
Haswell
Haxtun
Hayden
Hillrose
Holly
Holyoke
Hooper
Hot Sulphur Springs
Hotchkiss
Hudson
Hugo
Idaho Springs
Ignacio
Iliff
Jamestown
Johnstown
Julesburg
Keenesburg
Kersey
Kim
Kiowa
Kit Carson
Kremmling
La Jara
La Junta
La Veta
Lafayette
Lake City
Lakeside
Lakewood
Lamar
Larkspur
Las Animas
LaSalle
Leadville
Limon
Littleton
Lochbuie
Log Lane Village
Lone Tree
Longmont
Louisville
Loveland
Lyons
Manassa
Mancos
Manitou Springs
Manzanola
Marble
Mead
Meeker
Merino
Milliken
Minturn
Moffat
Monte Vista
Montezuma
Montrose
Monument
Morrison
Mount Crested Butte[28]
Mountain View
Mountain Village
Naturita
Nederland
New Castle
Northglenn
Norwood
Nucla
Nunn
Oak Creek
Olathe
Olney Springs
Ophir
Orchard City
Ordway
Otis
Ouray
Ovid
Pagosa Springs
Palisade
Palmer Lake
Paoli
Paonia
Parachute
Parker
Peetz
Pierce
Pitkin
Platteville
Poncha Springs
Pritchett
Pueblo
Ramah
Rangely
Raymer
Red Cliff
Rico
Ridgway
Rifle
Rockvale
Rocky Ford
Romeo
Rye
Saguache
Salida
San Luis
Sanford
Sawpit
Sedgwick
Seibert
Severance
Sheridan
Sheridan Lake
Silt
Silver Cliff
Silver Plume
Silverthorne
Silverton
Simla
Snowmass Village
South Fork
Springfield
Starkville
Steamboat Springs
Sterling
Stratton
Sugar City
Superior
Swink
Telluride
Thornton
Timnath
Trinidad
Two Buttes
Vail
Victor
Vilas
Vona
Walden
Walsenburg
Walsh
Ward
Wellington
Westcliffe
Westminster
Wheat Ridge
Wiggins
Wiley
Williamsburg
Windsor
Winter Park
Woodland Park
Wray
Yampa
Yuma
City /
Ciudad
County /
Condad
Zip Code /
Código Postal
Neighborhood /
Barrio
Please select...
Auraria
Cory - Merrill
Belcaro
Washington Park
Washington Park West
Speer
Cherry Creek
Country Club
Congress Park
City Park
Marston
Fort Logan
Barnum
Barnum West
West Colfax
West Highland
Sloan Lake
Berkeley
Regis
Chaffee Park
Highland
Athmar Park
Wellshire
University
Rosedale
Cheesman Park
Hilltop
Montclair
Hale
North Park Hill
South Park Hill
University Park
Platt Park
Overland
Ruby Hill
Kennedy
Hampden
Southmoor Park
Hampden South
Indian Creek
Goldsmith
University Hills
Harvey Park
Mar Lee
East Colfax
Capitol Hill
North Capitol Hill
Civic Center
CBD
Union Station
Central Park
Montbello
Lowry Field
Gateway - Green Valley Ranch
Harvey Park South
College View - South Platte
City Park West
Sun Valley
Valverde
Villa Park
Five Points
Globeville
Bear Valley
Virginia Village
Windsor
Washington Virginia Vale
Jefferson Park
Northeast Park Hill
Elyria Swansea
Baker
Clayton
Skyland
Lincoln Park
Whittier
Cole
Westwood
Sunnyside
DIA
Other - Not Listed
Email Address /
Correo Electrónico
Phone /
Teléfono preferido
Phone Type /
Tipo de teléfono preferido
Mobile /
Teléfono móvil
Landline /
Línea fija
What are your pronouns
/
Pronombres que utiliza
He/Him /
El
She/Her /
Ella
They/Them /
Ellos
Other pronouns /
Otros pronombres
Other pronouns
/
Otros pronombres:
Demographic Information
Gender /
Género
Female /
Mujer
Male /
Hombre
Non-binary/genderqueer / No-binario/género queer
Another gender identity /
Otra identidad de género
Prefer not to respond /
Prefiero no responder
Another gender identity /
Otr
a identidad de género
:
Veteran Status /
Estatus de veterano
I am a veteran /
Soy un veterano
I am NOT a veteran /
NO soy un veterano
Prefer not to respond /
Prefiero no responder
Disability /
Discapacidad
I have a disability /
Tenga una discapacidad
I do NOT have a disability /
NO tengo una discapacidad
Prefer not to respond /
Prefiero no responder
Race/Ethnicity /
Raza/Etnicidad
American Indian or Alaska Native /
Indio Americano o Nativo de Alaska
Asian /
Asi
ático
African American or Black /
Afroamericano o Herencia Negra
Hispanic or Latino /
Hispano o Latino
Native Hawaiian or Pacific Islander /
Nativo de Haw
ái o Islas del Pac
ífico
Middle Eastern or North African /
Oriente Medio o Norte de Africa
White /
Blanco
Other race, ethnicity, or origin /
Otro raza, etnicidad, o origen
Specify other race, ethnicity, or origin /
Especifique otro raza, etnicidad, o origen
Education and Household Information
What is the highest level of education that you have completed? /
¿Cuál es el nivel de educación más alto completado o diploma/titulo recibido?
Grade K-5 /
Primaria
Grade 6-8 /
Secundaria
Grade 9-12 /
Preparatoria
High School Diploma/GED /
Diploma de Preparatoria
Some College /
Cursos de universidad
Technical/ Trade School /
Escuela técnica
2-Year Degree /
Universidad, 2 años
4-Year Degree /
Universidad, 4 años
Advanced Degree /
Maestría
Did not attend school /
No fui a la escuela
What is your
gross (before taxes) annual household income
for the year? /
¿Cual es su ingreso anual de su hogar (antes de los impuestos)?
Please include your spouse/partner's income and all other sources, such as government assistance or self-employment /
Por favor incluya el ingreso de su pareja y otras fuentes de ingreso tales como ayuda para guardería
.
How many people are in your household
(including yourself)
? /
¿Cuantas personas viven con usted (incluyendo usted)?
Do you have access to a desktop or laptop computer at home?
/
¿Tiene acceso a una computadora en casa?
Yes / Si
No
Do you have access to the internet at home?
/
¿Tienes acceso a internet en casa?
Yes / Si
No
How did you hear about us? /
¿Cómo llegó a nosotros?
Select all that apply /
Seleccione todas las que corresponden:
Friend or family member /
Amigos o Familiares
Mi Casa flyer or brochure /
Folleto de Mi Casa
Mi Casa Staff /
Un empleado de Mi Casa
Mi Casa Website /
Sitio web de Mi Casa
Radio /
Estacion de Radio
Facebook
Instagram
Twitter
LinkedIn
YouTube
WorkNOW
The Fax Partnership
Community Organization /
Organizacion Comunitaria
Community Event/Resource Fair /
Un Evento Comunitario
Electronic Signature
/
Firma Electronica
Information Sharing
/
Divulgación de Información
Information collected from registration forms, questionnaires, and meetings with staff and partners may be used confidentially to help Mi Casa and its partners to evaluate and coordinate services. I grant permission to Mi Casa and its partners to share data confidentially among each other and with outside evaluators for the purpose of evaluating and coordinating services.
La información recabada a partir de los formularios de inscripción, los cuestionarios y las reuniones con el personal y colaboradores se podrá utilizar confidencialmente a fin de que Mi Casa y sus colaboradores puedan evaluar y coordinar los servicios que ofrecen. Otorgo permiso a Mi Casa y a sus colaboradores a divulgar datos de forma confidencial entre sí y con evaluadores externos a efectos de evaluar y coordinar servicios.
I agree that by typing my full name in the box below and entering today's date, I am electronically signing this form.
Estoy de acuerdo en que al escribir mi nombre completo y la fecha de hoy en los cuadros de abajo, estoy firmando electrónicamente este formulario.
Full Name /
Nombre Completo
Today's Date /
Fecha de Hoy
Contact Information
Mi Casa Resource Center
345 S Grove St, Denver, CO 80219
Main Line: (303) 573-1302
Business Hours: Mon-Thurs 8 a.m. - 6 p.m. | Fridays 8 a.m. - 4:30 p.m.
http://www.micasaresourcecenter.org/
|
info@MiCasaResourceCenter.org