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SAM Participant Inquiry Form
Individual Contact Information
Inidivdual's First Name
*
Individuals's Last Name
*
Home Address
City
*
State
*
Zip
*
Home Phone
Cell Phone
Email
What’s the best way to reach you?
*
Home Phone
Cell Phone
Email
What is your age?
*
18-24
25-54
55-64
65 or over
How do you describe yourself?
*
African American/Black
Caucasian/White
Hispanic/Latino
Asian
Other
What is the highest level of education you have completed?
*
High school/GED
Some college
College degree (B.A., B.S)
Graduate degree ( M.A., Ph.D.)
Which best describes your household Status?
*
Single
Married
Head of Household
Number of adults residing in your household?
*
Number of children residing in your household?
How many members of your household are currently working full-time?
*
How many members of your household are currently working part-time?
*
What is your approximate annual household income?
*
Under $24,999
$25,000-$49,999
$50,000-$64,999
Over $65,000
Are you currently facing or in the last 12 months have you experienced a financial crisis? If yes, please explain.
*
How did you learn about Smart About Money (SAM)?
*
Workplace
SAM Presentation
Media, SAM Flyer, Brochure, News Article or
Community Organization
Other
CLICK HERE IF PARTICIPANT IS BEING REFERRED BY A COMMUNITY ORGANIZATION.
Organization Name
Organization Street Address
City/State/Zip Code
Organization Contact
Contact Email
Contact Phone
Program service provided to household of referred client
SAM Participant Agreement
*
Yes
No
Are you able to commit to all of the following: (1) attending a SAM program interview, (2) attending 4 face-to-face budget coaching sessions with your assigned volunteer budget coach, (3) participating in 3 telephone check-ins with your assigned volunteer budget coach, (4) providing feedback throughout the program period to your referring organization’s program coordinator (5) participating in an exit interview with your referring organization’s program coordinator?
Sign by typing out your full name(s).
*
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