Empower Admissions Application Instructions:
By filling out this form, you are applying for admittance into the Empower Program. If you would like to be considered for residency within the house, please indicate so on the top of the application by checking “Residency”. Print all information requested clearly in ink
Your application must be accompanied by the following documentation:
Picture I.D.
Most recent record of medical exam (if within the last 30 days)
Answer all questions as accurately as possible. Your answers may or may not determine your eligibility.
Please note that by signing the application, you are legally stating what you have written is true.
The completion and review of this application by staff is the first step to becoming a part of the program. An interview with the Program Director will follow. If your application is being considered for residency, you will also need to fill out a Lease Application before being approved to live in the Empower House.

Personal Information

Full Name __________________________________________________
DOB ____________________ City and State of Birth ______________________________________
Social Security Number ______________________________
Phone ___________________ Cell Phone ________________ Email __________________________________
How were you referred to us? ____________________________________________________

Current Address ____________________________________________________________________
City _______________________________ State ____________ Zip ____________
Length of stay at this address? _________________________
Previous address if less than 1 year at the above: ______________________________________
City _________________ State ______ Zip __________ Length of Stay __________________
CPS Case Manager __________________________________________Phone Number __________________________

Do you have a current driver’s license? [ ]Yes [ ]No DL# _____________________ State ______ Suspended? ______

Have you ever been a resident at A & A Cottages or Empower? __________________________

Employment
Are you eligible to work in the U.S.? _______________

Are you currently employed? _____________________

Present Employer:________________________________________ Your Position:______________________
How Long? ____________________Supervisor’s Name: _________________________Phone #:________________
Street Address: _________________________________City:________________ State: __________Zip:___________
Do you like your current job? _________________ If not, why? _____________________________________________
____________________________________________________________________________________________
Previous Employer: ___________________________________ Your Position: ________________________
How Long? ____________________Supervisor’s Name: _________________________Phone #:________________
Street Address: _________________________________City:________________ State: __________Zip:___________
Previous Employer: ___________________________________ Your Position: ________________________
How Long? ____________________Supervisor’s Name: _________________________Phone #:________________
Street Address: _________________________________City:________________ State: __________Zip:___________
Previous Employer: ___________________________________ Your Position: ________________________
How Long? ____________________Supervisor’s Name: _________________________Phone #:________________
Street Address: _________________________________City:________________ State: __________Zip:___________
Education, Training and Experience
High School:
School name: __________________________________________________________________________________
School address: _______________________________________________________________________________
School city, state, zip: ____________________________________________________________________________
Number of years completed: ___________ Did you graduate? [ ] Y or [ ] N Degree / diploma earned: ______________
College / University:
School name: _______________________________________ Address:_______________________________________
School city, state, zip:_______________________________________________________________________________
Number of years completed: ______ Did you graduate? [ ] Y or [ ] N Degree / diploma earned: __________________
Vocational School:
Name: ________________________________________ Address:_________________________________________
City, state, zip:___________________________________________________________________
Number of years completed: ________ Did you graduate? [ ] Y or [ ] N Degree / diploma? : __________________
Military:
Branch: ________________________ Rank in Military:________________________
Total Years of Service: ________
Skills/duties: _____________________________________________________________________________
Related details:________________________________
Finaial History m a t e s
Financial Information

Gross Monthly Income: $ ________________________
Any Additional Income: $______________________ Source:_________________________________________
Any Additional Income: $______________________ Source:_________________________________________

Savings Account : Bank Name:_________________________ Balance: ________________
Checking Account: Bank Name: ________________________ Balance: ________________

Credit Card: _____________________________________________Balance: ______________________________
Credit Card: _____________________________________________Balance: ______________________________
Loan with ______________________________________________ Balance: ______________________________
Loan with ______________________________________________ Balance: ______________________________
Others? _____________________________________________________________________________________

Are you currently on Food Stamps? _______________ Amount per month: __________________________
Is your child currently on WIC? _________________

Household

Have you ever been married? _______________ If yes, explain: _________________________________________
____________________________________________________________________________________________
Are you pregnant? _____________ If yes, due date: ___________________ If yes, are you under medical care for the pregnancy? ___________________________________________________________

Children:
Name ________________________________________ Male / Female DOB ____________________
Is this child under your guardianship? __________ Is this child living with you now? _______________
Child’s school: _____________________________________ Child’s Daycare _______________________________
Does this child have any special needs? _______________________________________________________________
Name ________________________________________ Male / Female DOB ____________________
Is this child under your guardianship? __________ Is this child living with you now? _______________
Child’s school: _____________________________________ Child’s Daycare _______________________________
Does this child have any special needs? _______________________________________________________________
Name ________________________________________ Male / Female DOB ____________________
Is this child under your guardianship? __________ Is this child living with you now? _______________
Child’s school: _____________________________________ Child’s Daycare _______________________________
Does this child have any special needs? _______________________________________________________________

Are any of these children involved in a custody hearing? ________________ If yes, please explain ______________
_______________________________________________________________________________________________

Medical

Please describe the condition of your health: [ ] Excellent [ ] Good [ ] Fair [ ] Poor
Have you had a physical exam by a doctor in the last 30 days? __________ (If yes please attach proof)
Do you have any contagious or infectious illnesses? _________ Explain: ___________________________________ _______________________________________________________________________________________________
Do you have any medical conditions which require daily care? _________ Explain: ___________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________

Legal
Have you ever been convicted of a felony? Yes[ ] No [ ]
If yes, list convictions including dates and places: ______________________________________________________
_______________________________________________________________________________________________
Do you have a current warrant out for your arrest? Yes [ ] No [ ]
If yes, list in what city and county and reason: _________________________________________________________ _______________________________________________________________________________________________

Do you have outstanding fines that need to be paid or community service that needs to be fulfilled? Yes [ ] No [ ]
If yes, please give details ________________________________________________________________________________________________
________________________________________________________________________________________________

Have you ever been charged with / or convicted of sexual misconduct with a minor? ____________________________
If yes, explain ________________________________________________________________________________________________
________________________________________________________________________________________________

References
Please provide at least 3 references

Reference 1 Name: __________________________________________Relationship to you: _____________________
Length of Acquaintance:_____________________ Occupation: ______________________________________
Current Address: ______________________________________________Phone: _________________________

Reference 2 Name: __________________________________________Relationship to you: _____________________
Length of Acquaintance:_____________________ Occupation: ______________________________________
Current Address: ______________________________________________Phone: _________________________

Reference 3 Name: __________________________________________Relationship to you: _____________________
Length of Acquaintance: _____________________ Occupation: ______________________________________
Current Address: ______________________________________________Phone: _________________________

Who would we contact in case of emergency?
Name _____________________________________________ Phone ___________________________
Name _____________________________________________ Phone ___________________________

Initiative

Why do you want to live at Empower? _____________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ ____________________________________________________________________________________________ _____________________________________________________________________________________________

Do you feel you can apply yourself to work toward goals? ___________________________________________
What are some goals you currently have? ______________________________________________ ________________________________________________________________________________ ________________________________________________________________________________
Do you get angry easily? ______________ What makes you angriest? ____________________ ________________________________________________________________________________

Do you get discouraged easily? ________________

How do you keep yourself motivated? _________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________

If you feel you are facing an impossible situation, how do you deal with it? ____________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________

Can you comply with authority figures? ______________________________________________ _________________________________________________________________________________

If you are not currently in an education program/vocational training program, do you want to be? ________________ If yes, do you know which program/or school you would like to attend? ______ __________________________________________________________________________________________________________________________________________________________________

Do you have an interest in a career other than the job you are doing now? ______________________ _________________________________________________________________________________ _________________________________________________________________________________
Do you feel you can comply with the obligations of the Empower Program concerning stable employment and participation in education? ___________ Why?___________________________________________________________________________

Do you think it will be difficult living in a home with 3 other young women? ________________ ________________________________________________________________________________

What do you need the most help from Empower with? _________________________________________ ______________________________________________________________________________________
______________________________________________________________________________________


I warrant that the information supplied is true and correct and that I am at least 18 years of age or will be at the time of move-in. False or intentional omission of requested information will result in automatic denial. Applications must be fully completed with names, phone numbers and addresses as requested above. I understand that completion of this form is not a guarantee of acceptance into the program. A&A Cottages/The Empower Program warrants that any information derived from this application or outside sources will be kept confidential.

Signed ________________________________________________________________ Date _____________________________


For Office Use Only:
Received by: ___________________________________________________ Date _________________________________
Reviewed by: __________________________________________________ Date _______________________________

Approved for further interview? ___________________