Application - LeFlore County Bridges Out of Poverty

Getting Ahead Application (#3)

Getting Ahead in a Just-Gettin’-By World Class Application

Applications for Fall 2024 are closed, but you can still apply for Spring 2025. Spring 2025 applications will begin being reviewed in October 2024.

First Name

Last Name

Spouse First Name

Spouse Last Name

Date of Birth

Phone Number

Email Address

Address Line 1

Address Line 2

City

State

Zip Code

List the names of ALL adults in household:

Do your children live with you?

Yes

If no, where do they live?

Do you have visitation rights?

Yes

Are other children in the household?

Yes

List the names and ages of ALL children in the household:

Referral

Were you referred by someone?

Yes

If yes, list their name and phone number:

Employment

Are you currently employed?

Yes

Place of employment:

Job Title:

Length of employment:

Education

Income

Please select all sources of income:

If you selected other, please list:

Total approximate monthly income

Transportation

Do you have a working vehicle?

Yes

Are you on a bus route?

Yes

If neither of the above, list:

Current Service Agencies

Please select all agencies you are currently working with:

If you selected other, please list:

Your Struggles

Please select all areas where you are experiencing difficulties:

Check the following statements that are TRUE

If possible, I would like to eventually discontinue disability assistance.

I am not in a major crisis (untreated mental illness or drug/alcohol addiction, domestic violence situation, homeless, etc.)

I give permission for Bridges staff to talk to referring source about participant’s life situation, strengths and barriers

I am willing to work with others to become more self-sufficient, i.e. decrease public assistance

I am willing to participate in an interview with Bridges staff. It is my responsibility to arrange childcare during the interview.

I am willing to commit to a 18-20-week training course. (Approx. 3 hrs., one night per week, childcare & dinner provided)

I agree to a background check knowing that the information obtained will not be used to determine acceptance into the class, but for safety of all participants.

Please list the names and contact information of any professionals you receive ongoing support services from:

Alcohol / Drug Treatment

Counselor / Therapist

Vocational Rehab

Other:

Photo & Video Release

If you are selected as one of our participants/Investigators do you authorize Bridges staff to use pictures and videos of yourself and your children for promotion and inspiration to others?

Yes

If you selected no, please explain why:

Legal Notices

This is an application for the Getting Ahead Training; it does not guarantee you will be accepted. You will be contacted for an interview approximately one month prior to the next class starting. If your contact number changes after you have submitted this application, you are responsible for informing the Bridges staff as soon as possible.

If you are selected, be aware we will be serving meals. If you have any food allergies it is your responsibility to ask about ingredients. We are not responsible for any allergy or medical reaction you may have.

When you sign this page, you are giving permission for us to exchange information with the above people if necessary. Information will be used to determine eligibility for the LeFlore County Bridges Out of Poverty initiative and track progress toward goals.

By typing your name in the field below, you are signing that you understand all of the above and stating that all information is correct to the best of your knowledge.

Type your name, this serves as an electronic signature.