Family Empowerment Program Inquiry
First Name
Last Name
E-mail
Phone Number
Would you prefer we text or leave a voicemail at this number if we cannot reach you?
Text
Voicemail
Neither
Please select how many hours a month you are willing to invest in working on your selected goals: (some of this work will be with your Coach or other team members but much of it may be on your own).
0-5 Hours
5-10 Hours
10+ Hours
Net Monthly Income
Please select...
$0-$500
$501-$1000
$1001-$1500
$1501-$2000
$2001-$2500
$2501-$3000
$3001-$3500
$3501-$4000
$4001-$4500
$4501-$5000
$5001-$5500
$5501-$6000
Are you a resident of Davidson County?
Yes
No
Which of the following housing situations best describes your current living arrangement? Please Select all that apply :
I live in a shelter or transitional housing program.
I live “doubled-up” with friends or relatives because I do not have housing of my own.
I live in motels or at a campground because I cannot find or afford other housing.
I live in a car, abandoned building, or other location not normally designed for sleeping.
None of the above.
Household Size | You must list the name, date of birth and ethnicity for each person in your household!
Please select...
1
2
3
4
5
6
7
8
Person One in Household-Primary Contact
First Name
Last Name
DOB (MM/DD/YYYY)
Person Two in Household
First Name
Last Name
DOB (MM/DD/YYYY)
Person Three in Household
First Name
Last Name
DOB (MM/DD/YYYY)
Person Four in Household
First Name
Last Name
DOB (MM/DD/YYYY)
Person Five in Household
First Name
Last Name
DOB (MM/DD/YYYY)
Person Six in Household
First Name
Last Name
DOB (MM/DD/YYYY)
Person Seven in Household
First Name
Last Name
DOB (MM/DD/YYYY)
Person Eight in Household
First Name
Last Name
DOB (MM/DD/YYYY)
Are you currently seeking childcare?
Please select...
Yes
No
Do you currently have a child enrolled in the Child Development Center at St. Luke's Community House?
Please select...
Yes
No
How did you hear about the Family Empowerment Program?
Please select...
Community Organization
Church
Friends/Family
Teacher
Online/Social Media
STLCH child development center
STLCH Website
Which Organization?
Why are you interested in the Family Empowerment Program?
Contact Information