• A Little About Yourself

    Thank you for taking the time to fill out this application. Once you have submitted a completed application, you will be contacted by the Blessings Program Director.
  • Today's Date
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  • Format: 000-000-0000.
  • Can we contact you via text?*
  • How would you prefer to be contacted?*
  • Your Birth Date*
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  • Are you at least 18 years old?*

  • (If you are under 18 years of age, we must have your parent/guardian's consent to participate in this program. Please have a parent/guardian complete the following:

  • I   *   *   , legal guardian of   *   *   , give my permission for her to participate in and obtain services from the Blessings of NE Ohio program. I also permit Blessings of NE Ohio to contact me in order to verify consent.
    *   *   

  • A Little About Your Child(ren)

  • Child's Birth Date*
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  • Child's Birth Date
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  • Child's Birth Date
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  • Does your child(ren) live with you?*

  • Your Current Housing and Financial Situation

  • Is your child(ren)'s father(s) providing financial support?*
  • Is your child(ren)'s father(s) currently involved in your child(ren)'s live(s)?*
  • Are you on any government assistance? If so, please list*

  • Educational Information

  • Have you graduated high school?*
  • Are you currently enrolled in high school?*
  • What's the last grade you completed?*
  • Are you interested in pursuing a GED (General Educational Development) Degree?*
  • Are you currently attending college or trade school?*

  • Employment Information

  • Are you currently working?*
  • Do you plan on continuing to work there if you participate in the Blessings program?*

  • Personal Information

  • How did you hear about Blessings of NE Ohio?*
  • "Should I be accepted into Blessings of NE Ohio, I am willing to provide copies of:"*

  • Media Consent and Release

    Photographs may be taken during Blessings of NE Ohio events or Lifeskills Workshops for promotional purposes on our website and social media channels that may included images of volunteers, participants, and/or their children. Please answer the following concerning consent and release of any potential images for yourself and/or your children.

  • Consent and Release for MYSELF: I authorize and permit representatives of Blessings of NE Ohio to photograph, record and/or publish my name, statements, or images of myself for the purpose of promoting the Blessings of NE Ohio Program. I understand that Blessings may use my image in print form on the Blessings website, social media sites (ex. Facebook, Twitter, Instagram, etc.) or in video form. I understand my image will not be sold to any organization and will be used solely by Blessings of NE Ohio.
       *   

  • Consent and Release for MY CHILD(REN): I authorize and permit representatives of Blessings of NE Ohio to photograph, record and/or publish the statements or images of my child(ren) for the purpose of promoting the Blessings of NE Ohio Program. I understand that Blessings may use my child(ren)'s image in print form on the Blessings website, social media sites (ex. Facebook, Twitter, Instagram, etc.) or in vido form. I understand my child(ren)'s image will not be sold to any organization and will be used solely by Blessings of NE Ohio.
       *   

  • Today's Date
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  • Should be Empty: