MH Family Application

Children's Information Continued
Are your children U.S. citizens?*

YesNo
If no, explain:
Do you have at least 50% custody of the children listed above?*

YesNo
If no, please explain:
List first names of children who currently live with you:*
Have you or the father of your children ever been investigated for child abuse?*

YesNo
If yes, list child's name, explain incidents and outcomes:
List each child's name and describe the relationship they have with their father:*
List each child's name and describe legal custody, visitation activity and any safety concerns:*
Explain how you want custody status and or visitation agreements to change:
Do your children have any disabling conditions?*

YesNo
If yes, please describe:

Family's Education Information
Mother's Education (Select all that apply)

High School GraduateGEDTechnical CertificationSome College ClassesAssociates DegreeBachelors Degree
GED - Highest Grade Completed
Name and state of high school:
List name of any other schools attended, state, dates of attendance, and outcome:
Describe your future plans for school, area of study, and career:
List child's name, highest grade completed, current or last school or child care name, eligibility for school or childcare:
List any issues, problems or concerns with children attending school and/or childcare full-time:

Mother's Employment History
Current Employment Status*

Employed Part-timeEmployed Full-timeUnemployed
Current Employer
Weekly Schedule
Longest Employer
Dates of Employment
Employment Reference
Employer
Supervisor

First NameLast Name
City, State
Phone

Area CodePhone Number
Position
Weekly Hours
Pay Rate
$
Employer
Supervisor

First NameLast Name
City, State
Phone

Area CodePhone Number
Position
Weekly Hours
Pay Rate
$

Legal Information
Have you ever been arrested for any drug or alcohol related offenses?*

YesNo
If yes, dates, city, and offense?
Have you ever been arrested, charged of a crime, or convicted of a crime?*

YesNo
If yes, dates, city, and outcome?
Are you currently involved in any court or legal proceedings?*

YesNo
If yes, dates, city and reason?
Have you ever been involved with a gang?*

YesNo
If yes, dates, city, and involvement?

FAMILY LIFESTYLES
What is your personal opinion about faith, religion, and church?*
Describe what you know about God?*
What types of churches have you been a part of in your life?*
What was your home like when you were growing up?*
How do you parent your children?*
What time do you go to bed and what time do your children go to bed?*
What do you and your children like to do for relaxation?*
How is your family currently involved in your life?*
How are your friends currently involved in your life?*
Do you like time with people or time alone to get renewed?*
What's the hardest thing for you about people?*
Why do you want to join the Mary's Home community?*
How long do you desire to live at Mary's Home?*
What do you want to learn and accomplish at Mary's Home?*
What will be the biggest challenge for you if you live at Mary's Home?*
What is your plan for housing and care for your family if you are not accepted into Mary's Home or you don't like it?*

Personal References

List two professional and one personal reference who Mary's Home can call regarding your application for residency.
Name*

First NameLast Name
Relationship*
Phone *

Area CodePhone Number
Agency*
Length of Time Known*
Name

First NameLast Name
Relationship
Phone

Area CodePhone Number
Agency
Length of Time Known
Name*

First NameLast Name
Relationship*
Phone *

Area CodePhone Number
Length of Time Known*
MOTHER’S PERMISSION FOR RELEASE OF FAMILY INFORMATION

I GIVE MARY’S HOME PERMISSION TO CONTACT ALL REFERRALS AND REFERENCES AND TO RUN A CRIMINAL BACKGROUND CHECK AND A MOTOR VEHICLE RECORDS CHECK. I WILL SIGN AND SUBMIT THE PIKES PEAK REGION COMBINED AGENCY INFORMED CONSENT RELEASE TO BE USED IN THE APPLICATION PROCESS. I UNDERSTAND THAT IF I FAIL TO PROVIDE WRITTEN PERMISSION, MY APPLICATION WILL NOT BE PROCESSED.
Electronic Signature*

First NameMiddle NameLast Name
Date*

MonthDayYear
Date
ATTEST OF INFORMATION

I attest that all the information provided in this application is honest and accurate to the best of my knowledge. I understand that any deliberate misrepresentation of the information could result in my being denied acceptance into or expelled from this program.
Electronic Signature*

First NameMiddle NameLast Name
Date*

MonthDayYear
Date
Thank you for completing this application to Mary’s Home. We will notify you of the status of your application as soon as possible. May God bless you and encourage you and your children in your life journey.

Mary’s Home to the extent possible assures all applicants of confidential treatment of personal information. Mary’s Home shall obtain written permission for the release of information, unless the law otherwise authorizes such release. Limited information is used for anonymous statistical purposes for the purpose of increasing supportive services to homeless populations.
The Section Below is for Application Review-Office Use Only Please scroll to the bottom to click submit
Date Application Received
Release of Information Status
Application Status/Comments
Date Application Packet Reviewed
Outcome
Notification Date
Admit Date
Should be Empty: