New mom app test page 2 Home / New mom app test page 2 Jeremiah Program Application The new mom application as of January 2023 "*" indicates required fields First name* Middle name Last name* Date of birth* MM slash DD slash YYYY Phone number*Email address* Current physical mailing address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Race*Please select all that apply. American Indian or Alaskan Native Asian Black or African American Hispanic or Latina Native Hawaiian or Pacific Islander White Another Identity Prefer not to answer Please specify.* Which is your preferred JP campus? Please make a selection from the dropdown list below.*Austin, TXBaltimore, MDBoston, MABrooklyn, NYFargo-Moorhead, NDLas Vegas, NVRochester-Southeast MNMinneapolis, MNSt. Paul, MNHow did you learn about JP?*Please select all that apply. JP mom Family or friend (if not a JP mom) Community organization Social media Radio Print media Internet search/website If a JP mom, please list which mom referred you.* If a community organization, please list which partner referred you.* Do you have a high school diploma or GED? Please make a selection from the dropdown list below.*YesNoHave you already completed a bachelor's degree? Please make a selection from the dropdown list below.*YesNoAre you currently pregnant?*YesNoHow many children do you have (if pregnant, please count your unborn child)? Please make a selection from the dropdown list below.*1234List the date of birth for each of your children, starting with your youngest child and going up to your oldest.Child 1 date of birth (if pregnant, please enter your unborn child's due date here).* MM slash DD slash YYYY Do you have at least 50% custody of this child? Please make a selection from the dropdown list below.*YesNoChild 2 date of birth* MM slash DD slash YYYY Do you have at least 50% custody of this child? Please make a selection from the dropdown list below.*YesNoChild 3 date of birth* MM slash DD slash YYYY Do you have at least 50% custody of this child? Please make a selection from the dropdown list below.*YesNoChild 4 date of birth* MM slash DD slash YYYY Do you have at least 50% custody of this child? Please make a selection from the dropdown list below.*YesNoWhat is your marital status? Please make a selection from the dropdown list below.*Legally singleIn the process of divorcingMarried and living with and/or receiving support from my partnerWhat is your total annual income? Please make a selection from the dropdown list below.*$0-10,000$11,000-20,000$21,000-30,000$31,000-40,000$41,000-50,000$51,000-60,000$61,000-70,000$71,000-80,000$81,000+Are you interested in starting or staying in college for an associate's or bachelor's degree in the next 12 months? Please make a selection from the dropdown list below.*YesNoHave you started an associate's or bachelor's degree program in the past? Please make a selection from the dropdown list below.*YesNoRoughly how many credits did you earn?* Which of the following best describes you today? Please make a selection from the dropdown list below.*Currently attending collegeRegistered for college classesAccepted to collegeApplied to collegePlan to apply to college in the next yearHave credits but have not finished a degreeNot planning to apply to college in the next yearThinking about college but not sure where to startIf you are currently enrolled in college, do you have more than one year of school left? Please make a selection from the dropdown list below.*YesNoNot applicableAre you interested in pursuing Jeremiah Program housing? Please make a selection from the dropdown list below.*Yes, I would move in immediately.No, I have stable housing.Maybe, but I would need to learn more.How would you describe your current housing situation?*Are you interested in enrolling your child(ren) in the Jeremiah Program Child Development Center? Please make a selection from the dropdown list below.*YesNoUnsurePlease describe your current childcare situation for any of your children who are under 5.*What type of school does your child(ren) attend? Select all that apply.* Traditional public K-12 school Public charter K-12 school Private K-12 school Home school None Select AllJP aims to partner with you at the time that works best for you and your family. We have three options for starting Empowerment and Leadership, a 12-week experience that is the first step in your JP journey. Please choose the one that best meets your family's needs in the dropdown list below.*June 24-September 16, 2024September 16-December 9, 2024JP campuses value community and belonging, so you will be required to travel to the JP campus periodically (approximately twice a month). Please indicate your proximity to your selected campus.*I live within an hour of the JP campus and understand I will be required to travel to campus periodically (approximately twice a month).I live too far to travel to campus periodically (approximately twice a month).Please check the box to indicate you understand that JP will be calling, texting, or emailing you about your application.* I understand.
