M.O.M.S. Program Application Please enable JavaScript in your browser to complete this form.To qualify for the M.O.M.S. Program each of the following statements must be true: *I am a single mom of at least 1 child under 18.I live in either Dakota or Scott County.I do not currently live with my boyfriend or significant other.I have reliable transportation (to and from meetings in Burnsville).I desire to commit to a 3-year mentoring program.Name *FirstMiddleLastDate of Birth *Email *Phone Number *Address *Race and Ethnicity *African-AmericanAfricanAmerican IndianHispanicWhite or CaucasianOtherList your children's names, birthdates and genders: *Employment Status *I am unemployedI work 20 hours a week or lessI work 20-40+3 hours per weekI am on SSI, disability, or workmen’s compensationJob Retention and Stability *I am currently unemployedI have not been employed for over 6 monthsI have worked less than 6 months at present jobI have worked 6 months to a year at present jobI have worked more than 1 year at present jobIncome Sources (check all that apply) *No IncomeJobChild SupportPublic Cash BenefitsRent SubsidySnap Food AssistanceSSI DisabilityUnemploymentWorker’s CompensationOtherTransportation (check all that apply) *I have a reliable vehicleI have car insuranceI have had my license suspended in the pastI have had a DWI or similar offenseFinancial Concerns (check all that apply)I understand how to budgetI have a budget and I am living within itI am unable to pay bills each month without assistanceI misuse credit cards or have in the pastI have debt over $1000I have a poor credit ratingI have filed bankruptcy in the pastHousing Situation *I live in Section 8 or subsidized housingI am currently paying rent without assistanceI am having difficulty paying rentI own a homeI have lived in the same place more than 1 yearI have moved more than 2 times in the past yearHealth Insurance *I have no health insurance for myself and my childrenI have health insurance for just my childrenI have health insurance for both myself and my childrenI have insurance through the county assistance progamI have insurance through my jobI have insurance through another resourceList other insurance resource:Describe your current childcare situation: *Education *I have a High School Diploma or GEDI would like to get my GEDI have some college or trade schoolI have finished college or trade schoolI would like to go to college or trade schoolWrite the degree(s) you have completed or your area of interest if you want to go back to school:Social Support *Describe your social support network, including family and friends. Do you feel this is adequate? What are you looking for in social support?Parenting (check all that apply) *I feel adequate in my parentingI feel somewhat adequate in my parentingI feel inadequate in my parentingI have attended parenting classes in the pastI would like to attend parenting classesI have had a child protection case open beforeFather's Involvement *Describe the father’s involvement with your child(ren). If your children have different father’s, please describe each situation. Mental Health (check all that apply)I have been referred for a mental health assessment at some point in my lifeI have completed a mental health assessmentI have a current treatment planI am currently not complying with recommended treatmentI have a diagnosisI am currently on medication for my mental healthPlease Note: Answers about your mental health do not disqualify you from the M.O.M.S. Program. They are used to best assist you and your children in your specific situation. List any diagnosis (include date of diagnosis) and medications:Chemical Dependency (check all that apply) *I have abused alcohol in the pastI have abused drugs in the pastI currently abuse alcohol on occasionI currently drink alcohol but do not abuse itI currently use drugsI have been referred for a chemical dependency assessment at some pointI have followed the recommendation of assessmentI have not followed the recommendation of assessmentI have never been assessed but I think I may have a problemAdditional Information about your chemical dependency:Domestic Abuse (check all that apply) *I have been a victim of abuse as a childI have been a victim of abuse as an adultI have been a victim of domestic abuseI have had services to help with abuse issuesMy children have witnessed abuseMy children have been victims of physical, emotional, or sexual abuseThere is no history of abuse with my childrenFamily of Origin (check all that apply) *I grew up in a supportive homeI grew up in a non-supportive homeI grew up in an abusive homeI grew up in a single parent homeI grew up in a two parent homeI currently have a relationship with my familyI currently do not have a relationship with my familyWrite any other information you feel might be helpful for us to know about your family of origin:Resources *I know how to access the resources in my community that can be helpful to my familyI know how to access some resources, but need help with othersI do not know the resources available to me in my communityReligious Affiliation *I have no religious or church backgroundI have some church background but I am not active nowI am currently active in churchI have no church background but I am interested in spiritual thingsI am not interested in religious or spiritual thingsWhat church/denomination are you involved in (if applicable)?I am able to financially support my family Selected Value: 0 Rate yourself from 1-10 with 1 being the lowest and 10 being the highest.I am able to make and keep a budget Selected Value: 0 Rate yourself from 1-10 with 1 being the lowest and 10 being the highest.I am able to access the resources I need Selected Value: 0 Rate yourself from 1-10 with 1 being the lowest and 10 being the highest.I am connected to a strong support system Selected Value: 0 Rate yourself from 1-10 with 1 being the lowest and 10 being the highest.I am able to be proactive and not live in crisis Selected Value: 0 Rate yourself from 1-10 with 1 being the lowest and 10 being the highest.I am confident in my parenting skills Selected Value: 0 Rate yourself from 1-10 with 1 being the lowest and 10 being the highest.How do you think having a mentor could be helpful to you? *What are your three most important goals at this time? *Is there any other information you feel would be helpful for us to know as part of your application to the M.O.M.S. Program?Reference 1 *List the name, email, phone number, and relationship of someone who has known you for at least a year. Do not include family members. It is helpful (but not required) if you have talked to them about your interest in the M.O.M.S. Program. Reference 2 *List the name, email, phone number, and relationship of someone who has known you for at least a year. Do not include family members. It is helpful (but not required) if you have talked to them about your interest in the M.O.M.S. Program. Reference 3 *List the name, email, phone number, and relationship of someone who has known you for at least a year. Do not include family members. It is helpful (but not required) if you have talked to them about your interest in the M.O.M.S. Program. By typing my name below, I affirm that all information provided is accurate and truthful to the best of my knowledge. *FirstLastSubmit
