Program Participant Info

*Date of birth:

*Age:

*Are you currently using public assistant?
(Please select all that apply.)
NoneCash assistanceChildcare assistanceFood stampsHousingMedicaidSSI or RSIDUnemployment
*Highest Level of Education Completed
Less than 9th gradeSome High SchoolHigh School DiplomaGED / HiSETTechnical or Vocational DegreeSome College2-year Associate's degree4-year Bachelor's degreeSome Graduate SchoolGraduate, doctoral or terminal degree
*In order to help us measure our diversity practices, please select the ethnicity group you most closely identify with.
AsianBlack/African AmericanHispanic/LatinaMulti-RacialNative AmericanWhite/CaucasianOtherPrefer not to say
*Number of dependents under the age of 18 living at home with you

*Number of children total (even those outside your home)

*Current marital status
SingleMarriedDivorcedSeparatedWidowed
*Are you a single parent?
YesNo

*Are you a US veteran or active duty military?
NoI'm an immediate family member of a US veteranI'm the spouse of an active duty military memberYes, I'm dischargedYes, I'm activeYes, I'm retiredYes, I'm a reservist
*US citizenship status
US Born CitizenUS Naturalized CitizenImmigrantRefugee

*Have you ever been incarcerated?
YesNo

*What brings you to Dress for Success Quad Cities?
I'm unemployed and currently job searchingI have an upcoming job interviewI'm employed full-time but am thinking about going back on the job marketI'm employed part-time and looking for a full-time jobI'm employed but want to invest in my professional developmentI'm employed and want to connect and network with othersOther
If Other, please explain

If you have an interview scheduled, what is the date of your interview?
(If this does not apply, please skip this.)

If you have an interview scheduled, what company are you interviewing with?
(If this does not apply, please skip this.)

If you have an interview scheduled, what position you are interviewing for?
(If this does not apply, please skip this.)

*Do you currently make less than $12,760 annually (the US poverty level)?
YesNo

*Do you currently make less than than $28,600 annually (Scott County's living wage level)?
YesNo

*Do you currently make less than $36,480 (regional average annual salary level)?
YesNo

*How did you hear about Dress for Success Quad Cities?
Google searchSocial media (Facebook, Instagram, LinkedIn, etc.)Referred by another agencyA friend or family memberA fundraising event or saleA volunteer organizationOther

*If you were referred to us by another agency, please select the organization that referred you:
(If you were not referred by another organization, please select None.)
American Job CenterArc of the Quad Cities AreaArgrow's HouseBettendorf Police DepartmentBettendorf Schools Outreach ProgramBlack Hawk CollegeBloom TherapyCenter For Alcohol & Drug Services (CADS)Child Care Resource and Referral of Southeast IowaChildren & Families in IowaChristian CareChurches UnitedCommunity Action of Eastern IowaCommunity Home Partners (RIHA)Congregation of the Humility of MaryDavenport Public LibraryDeLaCerda HouseEastern Iowa Community College (EICC)Edwards UCCFamily ResourcesFirst Baptist Church of CordovaGenesis Bright BeginningsGilda's ClubGoodwill of the HeartlandHumble DwellingsHumility Homes & ServicesIllinois Army National GuardIllinois Department of Employment Security (IDES)Iowa Vocational Rehab Services (IVRS)IowaWORKS of Eastern IowaISU Scott County ExtensionLead(h)erLutheran Services of IowaMidwest Technical Institute (MTI)Milan Presbyterian ChurchMoline Housing AuthorityNarratives QCNational Able NetworkOrion Technical CollegePregnancy ResourcesProject NOWPurdue University GlobalQC Alliance for Immigrants & Refugees (QCAIR)Quad Cities Veterans Outreach CenterRobert Young Community Mental Health CenterRock Island County Council on Addictions (RICCA)Rock Island Public LibraryRock Island TownshipSafe Families for ChildrenSafer FoundationSalvation Army Quad CitiesSedona StaffingThe Abby CenterThe Center for Youth & Family SolutionsThe Clothing Center At Minnie's MaisonThe ProjectThird Missionary Baptist ChurchTransitions Mental Health ServicesTrinity College of Nursing & Health SciencesTwo Rivers YMCAUnited African OrganizationUnited Way Quad CitiesVera French Community Mental Health CenterWomen's Choice CenterWorld ReliefNone of these

If the organization you were referred by was not listed above, please enter the name of the organization:

Were you referred by a specific person at the organization? If so, please let us know who:

*Which of the following programs and services are you interested in?
(Please select all that apply.)
Networking Opportunities (opportunities to connect and network with other QC women)Financial Literacy ProgrammingJob FairsCareer & Professional Development WorkshopsGuest Speakers & WorkshopsPersonal Development Workshops (e.g., health/wellness, mindset, leadership, resources, etc.)Social Opportunities (opportunities to socialize with other QC women)Access to Free and Low-Cost Professional Clothing & Attire

*I understand that I must come alone to any scheduled appointments at Dress for Success Quad Cities, including the Interview Outfit appointment or career coaching sessions.
*I understand that if I do not call to cancel or show up for a scheduled appointment with Dress for Success Quad Cities, then I will not be able to use the StyleHER or Career Coaching services for 1 year. Please note: as long as you notify us prior to your scheduled appointment, we can reschedule your appointment up to 2 times.
*I understand that by utilizing the programs and services of Dress for Success Quad Cities that I agree to allow my likeness and statements to be captured and used for marketing purposes.

I would like to receive email notifications about upcoming workshops and events.