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 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

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211 E Fonner Park Rd, Grand Island, NE 68801 | Phone: (308) 384-9922 | info@ywca.org

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