Maternity Leave Match Savings Fund

First & Last Name:

First Name *

Last Name *

Pronouns:

She/her/hers
He/him/his
They/their/theirs
Other

Email: (Required)

Date of Birth:

Month

/

Day

/

Year

Age: (Required)

Social Security Number: (Required)

Home Address:

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Phone: (Required)

Alternate Phone:

Gender:

Female
Male
Trans/Transgender
Another gender
Prefer not to say

Race: (Please check all that apply)

Black/African American
Hispanic/Latino
White/Caucasian
Asian
Native Hawaiian/Other Pacific Islander
Native American/Alaskan Native
Other
Prefer not to say

How far into your pregnancy are you: (Required)

When is your due date: (Required)

How many children do you currently have (not including your current pregnancy): (Required)

How long are you planning on being on maternity leave? (Required)

What is your current living situation?

Family
Friends
Relatives
On own
Foster home
Homeless
Other

Is this living situation one you will remain in for at least 6 months?

Yes
No

Do you have a lease in your name?

Yes
No

Are you getting assistance from other programs or resources in the metro area?

Yes
No

If yes, please explain where:

Are you currently employed?

Yes
No

If yes, where are you working?

How many hours do you work in one week? (Required)

Are you able to save money for this program?

Yes
No

Are you currently enrolled in school? (GED, high school, college, etc.)

Yes
No

If yes, what school are you attending?

Is your child’s father going to be involved moving forward?

Yes
No
Not sure

Do you have people you can rely on in time of need?

Yes
No

If yes, please explain?

Rent (Required)

Utilities (Required)

Cell Phone (Required)

Internet (Required)

Car Payment/Lease (Required)

Gasoline/Bus Tickets (Required)

Car Insurance (Required)

Child Care (Required)

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Groceries (Required)

Total Monthly Income: (Required)

Total Monthly Expenses: (Required)

Money left over each month: (Required)

Are you willing to work with some type of coach or supportive person?

Yes
No

Are you willing to take a prenatal or newborn class?

Yes
No

Are you willing to participate in a post assessment?

Yes
No

Please list all the bills in your name. (Required)

Please explain how this program would benefit you. (Required)

I have read the above statement and agree to the terms of this program.

Agree

Today's Date

Month

/

Day

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Year

Maternity Leave Match Savings Fund

General Information

Gender

Race

Background Information

Financial Information

Support System

Current Monthly Budget

FIXED EXPENSES

Questions related to program

What bills are currently in your name?

How would this program be beneficial to you?

Omaha location

Lincoln location