ROMI's Family Support Program Application

Family Support Program Application

Thank you for your interest in Rooting On Me, Inc.'s Family Support Program. Our goal is to partner with families throughout the year by providing monthly life skills workshops, practical household support, and resources that help reduce everyday parenting stress while promoting healthy youth development. Please answer the questions below honestly. There are no right or wrong answers.
Parent Information
Parent/Guardian Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Method of Contact
Family Information
Number of adults in the home
Number of children
Ages of children
Family Needs
Biggest family challenges

Other
If you selected Other, please explain
Child Development
Area child(ren) should grow in
If Other, please explain
Monthly Support
Most helpful support types

Other
If Other, please explain
Commitment
Will you commit to attending regularly?
If you selected Maybe, please explain
Learning Interests
Top 3 life skills you want to learn

Other
If you selected Other, please explain
Program Commitment and Signature
Program Commitment
By signing below, I understand that:

I am applying to participate in Rooting On Me, Inc.'s Family Support Program.
I understand this program is designed as a partnership to help strengthen families through education, practical resources, and ongoing support.
I agree to make every effort to attend one monthly life skills meeting.
I understand participation helps my family receive monthly Care Support Packets while supplies and funding are available.
Parent/Guardian Signature
Date

MonthDayYear
Date
Should be Empty:

Family Support Program Application

Parent Information

Family Information

Family Needs

Child Development

Monthly Support

Commitment

Learning Interests

Program Commitment and Signature