2023 Mentee Participant Enrollment Form

Please complete this FREE application to work with the Money Mentors program. We will use this information to pair you with a Money Mentor. All information will be kept confidential.

Questions are asked about your job status, how often you are paid, the number of family members and your financial concerns to find a good match for you. Some questions, like "What's your age?", are asked to learn about our participants and support the success of the program.

Thank you for signing up to be a Mentee Participant!

Contact Information

First Name

Last Name

Street Address

Street Address 2

City

State

ZIP

Daytime Phone

Evening Phone

E-mail Address

What is your age?

Are you currently serving as a volunteer with other organizations?*

Yes

What is the best way to reach you?

Phone

What are the best days and times for you (and other adults in the household, if possible) to meet with a Money Mentor?

Which town and what part of town would be most convenient for you to meet with a Money Mentor?

What is your age?

What is your job status?

Full-time

Part-time

Seasonal

Unemployed

Student

Retired

What is your occupation?

What is your household annual gross income (income for the year before taxes)? Please enter a number (Do not include any commas, decimals, or symbols).

How often are you paid?

Weekly

Twice a month

Monthly

Age of other members of your household who share the income.

What is your housing status?

Own

Rent

Living with others

Shelter

Other

How much is your current monthly rent or house payment?

Below is a list of financial concerns. Which of these concern you? Please list your top 3 concerns in the order that they most concern you (ex. #1 - highest concern, #2 next concern, etc.) Click on the down arrow to see more options

How did you find out about the Money Mentor program? (Check all that apply)

E-Newsletter or Emails

Flyer or Poster

Library

Newspaper

Personal Referrals (e.g. Friend, Co-Worker, etc.)

Facebook

Radio or TV

University of Illinois Extension Website

Other

What help would you like from a Money Mentor?

What is your preferred language to be used with a Money Mentor?

Civil Rights Compliance - Participant Info

As part of our commitment to providing equal opportunities in our programming, University of Illinois Extension is required to collect and report overall statistics about the race, ethnicity, and gender of program participants. Your responses are voluntary and appreciated.

Gender

Ethnicity

Race