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Welcome to Step By Step!
We're SO glad you're here!
Please fill out our registration form below, and our program team will contact you soon!
General Information
First Name
*
Middle Initial
Last Name
*
One of our primary forms of communication with SBS Moms is through Facebook. If you are on Facebook, list your Facebook name here.
Birthday (mm/dd/yyyy)
*
+
Gender
*
Male
Female
Other
Street Address (Include Apartment # if needed)
*
City
*
State
*
Zip Code
*
Phone Number
*
Alternate Phone Number
Preferred Method Of Communication
*
Email
Mail
Phone
Text
Facebook
Ethnicity
*
African-American
Asian American
Caucasian
Hispanic
Multi-Racial
Native American
Other
Prefer Not to Identify
Marital Status
*
Single
Married
Co-Habitate with Partner
Seperated
Divorced
Widowed
Have you ever been in foster care?
*
Past Care
Currently In Care
Independent Living
Aged Out
N/A
Do you currently have an open case with DCBS (Department for Community Based Services, includes CPS)?
*
Yes
No
What is the name of your social worker?
*
Education
Select your current education level:
*
Drop Out
In Middle School
In High School
High School Grad
In GED
GED
In College
College Grad
Are you currently in school?
*
Yes
No
Select your school:
BCTC
Bryan Station
CTE
Dunbar
EKU
Family Care Center
Henry Clay
Lafayette
Martin Luther King
Sullivan
Tates Creek
University of Kentucky
Expected Graduation Date
+
Are you interested in returning to school or completing your GED, whichever is appropriate?
*
Yes
No
Employment
Are you currently employed?
*
Not Employed
Part Time
Full Time
Where?
*
Job Title
*
What type of work do you do?
Other Information
Currently, are you receiving any of the following? Check all that apply.
*
Child Support
KTAP
Child Care Assistance
SNAP
WIC
Medicaid
SSI
SSDI
Most commonly used form of transportation
*
Own car
City bus
Friends/Family
Uber/Lyft
Other
How did you find out about Step By Step?
*
What is your main reason for coming to Step By Step?
*
Emergency Contact Information
Name
*
Address (If different than your's)
Phone Number
*
Are you under the age of 18?
*
Yes
No
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