Apply to Cherish House

Cherish House Application

The first step to admission into Cherish House is by filling out the application below. Please fill in as much information as you are able. Upon receiving your application we will contact you for next steps in the process.

We understand that filling out the application is a courageous step. We desire to walk along side of you as we see if the Cherish House is the right place for you to stay. You do not commit to coming to Cherish House by filling out the application. We look forward to speaking with you!

Cherish House Application

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Cell Phone
Home Phone
Email*
Date of Birth*
Date Format: MM slash DD slash YYYY
Social Security Number*
Drivers License Number
Race*
Height*
Are you a US Citizen?*
- Yes
- No
Does your family speak and understand English?*
- Yes
- No
Desire Entry Date to Cherish House*
Date Format: MM slash DD slash YYYY
How did you hear about Cherish House?
Currently, what are you plans for the baby after delivery? *
- Adoption
- Parenting
- Undecided
FAMILY INFORMATION
What is your current living situation?*
- Living with Parents/Gaurians
- Living independently
- Other
If other, please explain.
PARENT(S)/GUARDIAN OF APPLICATION (IF UNDER 18 AND NOT LIVING WITH PARENTS)
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Cell Phone
Cell Phone
Email
Place of Employment
Years Employed at Current Work Place
If guardian, reason for guardianship and length of time as guardian?
CHILDREN OF APPLICANT
Do you have any other children? If yes, what are their names, ages, and who are they currently living with?
EDUCATION INFORMATION
IF A RESIDENT HAS NOT RECEIVED HER DIPLOMA OR GED, THE RESIDENT MUST PARTICIPATE IN THE FOLLOWING EDUCATION OPTIONS: 1) WITH THE ASSISTANCE OF THE HOUSE PARENTS, ENROLL IN THE GED PROGRAM AT IOWA LAKES COMMUNITY COLLEGE 2) ATTEND SPIRIT LAKE MIDDLE OR HIGH SCHOOL 3) PARTICIPATE IN AN ALTERNATIVE EDUCATION PROGRAM THROUGH IOWA LAKES COMMUNITY COLLEGE
Have you completed high school or a GED?*
- Yes
- No
Current Education Level*
LEGAL INFORMATION
Have you ever been arrested?
- Yes
- No
If Yes, Please Explain
Are you involved with any court proceedings at this time?
- Yes
- No
If yes, please explain
Other than arrest, have you ever been in trouble with the law?*
- Yes
- No
If yes, please explain.
Have you ever been on probation?*
- Yes
- No
If yes, for what?
SPIRITUAL INFORMATION
Are you willing to attend church with the house parents while staying at Cherish House?*
- Yes
- No
Will you be receptive to Christian teaching while at Cherish House?*
- Yes
- No
FINANCIAL INFORMATION
IF YOU DO NOT HAVE INSURANCE, YOU MAY BE ELIGIBLE FOR TITLE IXX (MEDICAID) OR OTHER STATE GOVERNMENT COVERAGE. PLEASE BRING THE FOLLOWING WHEN YOU ARRIVE FOR CHECK IN AT CHERISH HOUSE (COPIES WILL BE MADE): SOCIAL SECURITY CARD PICTURE ID (DRIVER'S LICENSE, STATE ID, SCHOOL ID, PASSPORT, ETC) BIRTH CERTIFICATE IF YOU ARE INSURED OR COVERED UNDER A FAMILY POLICY, PLEASE COMPLETE THE FOLLOWING
Insurance Company
Policy Number
Phone
Full Name of Person on Policy
Policy Holder's Social Security Number
Are you on WIC?*
- Yes
- No
Title XIX (Medicaid)*
Check all that apply.
- I have Title XIX (Medicaid) now
- Planning to apply for Title XIX
- Need information about Title XIX
- Do not want to apply or do not quality for Title XIX
- I do not have insurance or medical coverage
- Other
If you do not have insurance and do not qualify for Title XIX, how will you plan to pay for the medical expenses you will be incurring while at Cherish House?
FATHER OF THE BABY (FOB) INFORMATION
Is the FOB aware that you are pregnant?*
- Yes
- No
- Unsure
Does the FOB support you coming to Cherish House?*
- Yes
- No
- He's unaware
- I'm unsure
FOB's Name*
First Last
FOB's Age*
FOB's Race*
FOB's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
SUPPORT SYSTEM INFORMATION
What are your fears or concerns about coming to Cherish House?*
What do you hope to accomplish or learn while at Cherish House?*
Do you want to come to Cherish House?*
- Yes
- No
- Not sure right now
CERTIFICATION & SIGNATURES
I CERTIFY THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF, THE ANSWERS GIVEN BY ME IN THE FORGOING QUESTIONS AND THE STATEMENTS ARE CORRECT AND COMPLETE. I UNDERSTAND THAT ANY OMISSIONS, MISLEADING, OR FALSE INFORMATION CONTAINED IN THIS APPLICATION MAY RESULT IN MY IMMEDIATE DISCHARGE FROM CHERISH HOUSE. I ALSO AUTHORIZE CHERISH HOUSE OR CHERISH CENTER STAFF TO VERIFY MY INFORMATION WITH ANY MEDICAL CARE PROVIDERS, COMPANIES, SCHOOLS, MENTAL HEALTH AGENCIES, LAW ENFORCEMENT AGENCIES, OR PERSONS TO GIVE ANY INFORMATION REQUESTED REGARDING MY MEDICAL HISTORY, MENTAL HEALTH STATUS, EMPLOYMENT, CHARACTER, EXPERIENCE, AND/OR SUITABILITY FOR RESIDENCY AT CHERISH HOUSE. I UNDERSTAND THAT INFORMATION IS SOUGHT WITH CONFIDENTIALITY AND WILL NOT BE MADE PUBLIC BUT WILL REMAIN IN A PRIVATE AND CONFIDENTIAL FILE. IN ADDITION, A COPY OF THIS AUTHORIZATION IS AS VALID AS THE ORIGINAL AND SHOULD BE RECOGNIZED AS SUCH.
Signature of Application*
Date of Application*
Date Format: MM slash DD slash YYYY
CAPTCHA
Signature of Parent Guardian (if under 18)
Date of Application
Date Format: MM slash DD slash YYYY

Sign Up for Updates

Cherish House Application

FAMILY INFORMATION

PARENT(S)/GUARDIAN OF APPLICATION (IF UNDER 18 AND NOT LIVING WITH PARENTS)

CHILDREN OF APPLICANT

EDUCATION INFORMATION

LEGAL INFORMATION

SPIRITUAL INFORMATION

FINANCIAL INFORMATION

FATHER OF THE BABY (FOB) INFORMATION

SUPPORT SYSTEM INFORMATION

CERTIFICATION & SIGNATURES

Footer