EcSA Interest Form

I am interested in:(Required)

Becoming a mentor for program participants

Participating in the program

Contact Information

Name

First Last

Email

Send me email about:(Required)

All Opportunity Council News & Updates

Only news related to financial literacy and wellness

Only information directly related to my answers on this form

Phone

Preferred Contact Method

Phone

Email

Text

Where are you located?

Whatcom County

Island County

Other

How did you hear about the EcSA program?(Required)

Friends or Family

Social Media

Flyer

Opportunity Council Website

Opportunity Council Staff

Northwest Workforce Council

DSHS Staff

Other

Please tell us about your interest in the EcSA program.

Household Information

How many people are in your household?

What is the total annual income for your household?

Please estimated based on all sources of income for those living within your household. Please use numbers only and no special characters like "$" or ",".

Do you have access to reliable internet service and a computer or tablet.

Yes

No

Other

Employment Information

Are you currently employed?

Yes - Full Time

Yes - Part Time

No

Other

Please describe your current employment plans and goals.

Example: If you are currently employed, do you want to increase your hours, receive new training, or increase your pay? If you are currently unemployed, do you intend to become employed or participate in job training in the future?

Additional Information

Your Age

Will translation assistance help you complete this class?

Yes

No

Language to be translated

Please share any additional questions or comments you may have.

Economic Security for All Interest Form

Contact Information

Household Information

Employment Information

Additional Information