I Want To Join!
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Please fill out the application and when you get to the end of the form hit the tab button to continue to the next set of questions. Once your application has been received someone will contact you shortly.

 

Eligibility Requirements:

I’m between the ages of 13 and 23 years old.

I am parenting my child.

I am a US Citizen or documented resident.

Yes
No
Friend
Human Services
Television
Radio
Social Media (Facebook, Instagram, etc)
Internet Search (Google, etc)
School
Church
Teacher
Medical Office
Other
/ /
American Indian/Alaskan Native
Asian
African American/Black
Caucasian/White
Hispanic
Native Hawaiian or Pacific Islander
Other
US Citizen
Non-citizen
Lawful Status (i.e, DACA)
Applied for Lawful Status
Yes
No
Yes
No
My child is with me all the time
6 nights a week
5 nights a week
4 nights a week
3 nights a week
2 nights a week
1 night a week
I do not Spend any nights with my child
Male
Female
/ /
American Indian/Alaskan Native
Asian
African American/Black
Caucasian/White
Hispanic
Native Hawaiian or Pacific Islander
Other
Allergies
Epilepsy
Speech Issues
Physical Development Issues
Hearing Issues
Vision Issues
Other
English
Spanish
English & Spanish
Other
Yes
No
Yes
No
Yes
No
Yes
No
Single
Dating
Engaged
Legally Married
Separated
Divorced/Widowed
Alone
Spouse
Domestic Partner/Boyfriend
Extended Multi-family
Both Parents
Single Parent
Grandparent
Foster Home
Hotel/Motel
Car
Transitional Housing
Friend(s)
Other
Mother
Father
Boyfriend
Girlfriend
Fiancé
Spouse
Brother
Sister
Children
Ex
No one at all
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Own a car
Bus/Train
Lyft/Uber
Other
Yes
No
Alcohol
Cocaine
Meth
Prescription Drugs
None of the Above
Other
Yes
No
Yes
No
Nervous Breakdown
Depression
Strange/Peculiar Behavior
Suicide Attempts
Anxiety Disorder
Memory Loss
Violent Behavior
Panic Attacks
Other
Anxiety or Tension
Suicide Attempts
Wanting to harm yourself
Trouble controlling violent behavior
Trouble understanding
Concentrating or remembering things
Depression
Thoughts of suicide
Panic attacks
None of the above
Yes
No
Shoplifting
Forgery
Failure to appear
Vandalism
Child Neglect
DUI/DWI
Theft
Child Abuse
None of the above
Other
Probation
Parole
Court Supervision
None of the above
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
GED
Residential Program
College/Job Help
Parenting Classes
Healthy Relationship Classes
Legal Assistance (i.e. protection orders, parenting orders)
Budgeting/Finance Classes
Supportive Adult Relationships
Meeting other Teen moms through activities
Other

* Required