Fatherheart Application - Living Alternatives

East texas father heart maternity home campus sidewalk with two young ladies pushing their babies in strollers

NEW Fatherheart Resident Application

Application Information

Name(Required)

Date of Birth(Required)

Cell Phone(Required)

Email(Required)

Select your current living situation.(Required)

Address

Street Address Address Line 2 City State ZIP Code

What is your age?(Required)

Social Security #(Required)

This is used for background checks only.

Have you graduated high school or obtained a GED?(Required)

Marital Status(Required)

Estimated pregnancy due date?(Required)

Are You Employed?(Required)

Employer

Employer's Phone Number

Please Upload a Photo of Yourself(Required)

Max. file size: 256 MB.

Who referred you to Fatherheart?

Have you had prenatal care with this pregnancy?(Required)

Do you have any dependent children living with you?(Required)

Please list their names and ages:

Do you currently have any form of Health Insurance?(Required)

Do you currently have a Pregnancy Medicaid in Texas ID#?

Are you currently on WIC?(Required)

Parenting & Group Living

Fatherheart Maternity Home is a welcoming, loving place for women to be a part of a program that enriches their life and prepares them for the future. There are a variety of program opportunities offered that each resident will be expected to take advantage of and participate in while living in the home.

Please explain why you would like to live at Fatherheart Maternity Home.(Required)

Acknowledgments and Agreements

Background Check Consent(Required)

I understand Fatherheart Maternity Home will conduct a background check before I will be considered as a resident, and I give them permission to do so.

Request for Admission(Required)

I believe it is in the best interest for me and my unborn child to become a resident of Fatherheart Maternity Home. It is my intention to actively participate in the programs in place to benefit me and my unborn child.

Application Admission(Required)

All of the information provided on this form is true and accurate to the best of ability.

NEW Fatherheart Resident Application

Application Information

Parenting & Group Living

Acknowledgments and Agreements

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