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Homeownership Workshops
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Contact information

First name

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Last name

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Phone

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Email address

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Date of birth

Month

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Day

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Year

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Background

Languages

Address

Address

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Apartment, suite, etc. (optional)
City

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State

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ZIP code

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Experience

Skills
Interests

Additional details

T-Shirt size

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Dietary restriction
Allergies
Physical limitations

The following questions are mandatory and will help provide insight into the experiences and needs of families seeking affordable and stable housing opportunities in the Quad Cities and help Habitat QC better understand how we can help serve our community.  Thank you for your responses.

What is your age range?

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What is your gender identity?

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What is your race / ethnic background?

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What is your current relationship status?

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How many people currently live in your household?

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How many children live in your household?

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What is your highest level of education completed?

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What is your current employment status?

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Where do you currently work?

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What support systems or family strengths can you rely on to support you through difficult times?

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Approximately how long have you lived in the Quad Cities?

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Were you born in the Quad Cities?

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If you're not from the Quad Cities, please explain where you are from.

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What type of housing do you reside in?

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If you are renting, when do you need to renew your lease?

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Select any of the following that has influenced your decision to apply to for a Habitat home?

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On a scale from 1- 5, how stressful is your housing situation? (1= Not Stressed, 5 = Extremely Stressed)

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Does your current housing situation affect any of the following?

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How do you hope that owning a Habitat home will benefit your families future?

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Please describe yourself (Who are you? What are your interests? What do you value in life? What are your goals / dreams? How do you define a successful life?)

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Emergency contact

Relationship

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First name

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Last name

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Phone

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Phone type
Email address

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Confirmation

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