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Women’s Empowerment Center Class Enrollment Form
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What We’re Doing
Empowerment
Women’s Empowerment Center Class Enrollment Form
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Women's Empowerment Center Class Enrollment Form
The YWCA collects client's information to meet specific federal, state, and local reporting requirements and to improve quality and service delivery. YWCA protects all clients' personally identifiable information from unauthorized disclosure. If you know someone who does not have access to online registration, have them call (308) 384-9922 to register.
Available Classes:
Stress Less with Mindfulness with Mary Ann Kalinay & Anne Kruse | August 23, 2021 - 5-6 pm
Cost: option pricing from $0 - $15 based on ability to pay
Complete the form below and click submit to move on to the section to select your class or classes and pay.
Name
*
First
Last
Date of Birth
*
MM slash DD slash YYYY
Phone Number
*
Email
*
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
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Bahrain
Bangladesh
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Belize
Benin
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Bosnia and Herzegovina
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Bouvet Island
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Burundi
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Cameroon
Canada
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Central African Republic
Chad
Chile
China
Christmas Island
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Congo, Democratic Republic of the
Cook Islands
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Croatia
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Curaçao
Cyprus
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Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
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Greece
Greenland
Grenada
Guadeloupe
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Guinea-Bissau
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Hungary
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India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
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Lithuania
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Macao
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Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
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Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
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Pitcairn
Poland
Portugal
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Qatar
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Saint Helena, Ascension and Tristan da Cunha
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Samoa
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Sint Maarten
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Slovenia
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Somalia
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South Sudan
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Sudan
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Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
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Tonga
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Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Which best describes your gender?
*
Gender non-conforming
Female
Male
Non-binary
Prefer not to say
Trans-female
Trans-male
What best describes your Ethnicity? (Check one)
*
Hispanic/Latino
Non Hispanic/Latino
Prefer not to say
What best describes your race? (Check one)
*
American Indian or Alaskan Native
Asian
Asian & White
Black or African American
Black/African American/ & White
Native Hawaiian or Other Pacific Islander
White
Prefer not to say
Do you have the legal right to work in the US?
*
Yes
No
Unsure
Have you been affected by COVID-19
*
Yes
No
Have experienced verbal, physical, or emotional violence?
*
Yes
No
Maybe
Which best describes your household? Households includes, but not limited to the following-regardless of actual or perceived sexual orientation, gender identity, or marital status-a single person or a group of persons residing together (Check One)
*
Dual Headed Household
Single Female Head of Household
Single Male Head of Household
Number of person(s) living in your household including yourself:
*
Hall County, NE HUD Metro FMR Area
Household of:
1
2
3
3
4
5
6
7
Extremely low income
14,700
16,190
21,330
25,750
30,170
34,590
39,010
43,430
Very low income
24,500
28,000
31,500
35,000
37,800
40,600
43,400
46,200
Low income
39,200
44,800
50,400
56,000
60,500
65,000
69,450
73,950
Use the above table to determine your selection. Total estimated income for the next 12 months for all adults members living in the household including yourself:
*
Extremely low income
Very low income
Low income
Client Signature
*
Date
*
MM slash DD slash YYYY