Program Application

The program application gives us information about you, your interests and your needs. The information helps us evaluate resources you might need, and referrals the program might be able to make that are outside of Jeremiah Program.

Much of this information is confidential and may be used by us to determine how to best serve your needs and those of your family. If you are uncomfortable with any question, you may omit answering it. You may also contact the Admission Coordinator’s office at 651-332-5017 for more information about any question or how this information is used.

Jeremiah Program is committed to compliance with all local, state, and federal civil rights and human rights laws that prohibit discrimination in providing educational, social service, and housing opportunities. Jeremiah Program does not discriminate against any applicant or participant on the basis of race, color, religion, creed, national origin, marital status, family status, status with regard to receipt of public assistance, physical or mental disability, or affectional preference.

Jeremiah Program does provide reasonable accommodations for persons with disabilities. Reasonable accommodations in rules, policies, practices and services will be allowed to give persons with disabilities equal opportunity to use and enjoy housing provided by Jeremiah Program or to participate in other aspects of the program, provided such accommodations do not impose an undue hardship. Applicants or program participants with disabilities seeking reasonable accommodations must contact the Director of Family Services to make an accommodation request.

Download application forms:

Program Application

Application info sheet new 2011

Approved Post-Secondary Institutions

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Twin Cities residents only. All fields required.

Campus Location

Applicants may indicate a preference for either the Minneapolis or Saint Paul campus; however, there is no guarantee that preferences will be honored. Please check your preference below.
 Minneapolis St. Paul First available option

Personal Information
First Name
Middle Name
Last Name
Address
City
State
Zip
Is this address a shelter?  Yes No
Gender  Male Female
Date of birth
Have you experienced *Long-term Homelessness?
 Yes No

*Long-term homelessness is defined as someone lacking a permanent place to live, continuously for one year or more, or at least four times in the past three years or less. This can include staying in a shelter, a place not meant for habitation (e.g., a vehicle, an abandoned building, bus/train station/airport or anywhere outside), or couch hopping.

Current marital status:  Single Separated Divorced
Home number
Can we leave messages for you here? Yes No
Work number
Can we leave messages for you here? Yes No
Cell number
Can we leave messages for you here? Yes No
Where is the best place to contact you?  Home Work Cell Email
Email
How did you hear about Jeremiah Program?
Have you ever been known by another last name?
 Yes No
If yes, what is it?
Are you a U.S. citizen?  Yes No
Were you born in the U.S.?  Yes No
Are you a resident of MN?  Yes No
How long have you lived in MN?
Where did you live before MN?
If you lived in another state, why did you move to Minnesota?
Ethnic Background:
Children's Information

Please keep in mind that in order to qualify, ALL children must be under the age of 5 at the time of applications.
Are you pregnant at this time?
 Yes No

If yes, what is your due date?

List Children:
  Children's name Sex Date of birth Ethnic background
1
2
3
4
Do you have a childcare provider for your child(ren)?  Yes No
If so, who is the childcare provider?
Do you receive childcare assistance through a county program?  Yes No
If yes, how many hours per week are you authorized?
If no, are you on any waiting lists for childcare assistance?  Yes No
Custody Arrangement:
 Sole Physical Custody Joint Physical Custody Father has Sole Physical Custody Other
If Other:
Employment
Are you Currently Employed?  Yes No
Employer
Position
Work Phone
Length of Employment
Hours per Week
Rate of Pay
If unemployed, are you currently job searching?  Yes No
Income Information
What is your estimated total yearly income? $
Whare are your current sources of income?
Employment: $/month
Public Assistance: $/month
Other: $/month
If you receive any county assistance, please list the county name:
Do you have a Section 8 Voucher?  Yes No
Education
Type of Degree:  Diploma GED None Other
If other, please list:
Name of school currently accepted to or enrolled in:
Location of School:
What certification or degree are you seeking?
 Certificate Diploma Associates Bachelors None Other
If other, please specify:
Start Date:
Anticipated graduation date:
What is your major field of study?
What is your current status?  Good Standing Probation Suspension Other
Health Information
Do you have any special health care needs?  Yes No
If yes, what are they?
Does your child(ren) have any special health care needs?  Yes No
If yes, what are they?
Is there any special help, accommodations or modifications that you or your child(ren) might need due to a disability, handicap condition, or other circumstances?
Why Jeremiah Program?

Why do you want to attend your chosen post secondary educational program? How do you think that this education will impact your life?

How do you think that your education will impact your child(ren)’s life? Your family’s life as a whole?

Jeremiah Program is committed to compliance with all local, state, and federal civil rights and human rights laws that prohibit discrimination in providing educational, social service, and housing opportunities. Jeremiah Program does not discriminate against any applicant or participant on the basis of race, color, religion, creed, national origin, marital status, familial status, status with regard to receipt of public assistance, physical or mental disability, or affectional preference.

Jeremiah Program does provide reasonable accommodations for persons with disabilities. Reasonable accommodations in rules, policies, practices, and services will be allowed to give persons with disabilities an equal opportunity to use and enjoy housing provided by Jeremiah Program or to participate in other aspects of the program, provided such accommodations do not impose an undue hardship on the organization. Applicants or program participants with disabilities seeking reasonable accommodations must contact the Executive Director to make an accommodation request.

Please read the following statement and initial below:

The information in this application is true and correct. I hereby grant permission to Jeremiah Program to seek the release of personal information concerning me from sources reported in this application including, but not limited to: government agencies, educational institutions, current and former employers, health care providers, and mental/chemical health facilities. I understand that my signed consent below will operate as consent for the purposes of complying with the Health Insurance Portability and Accountability Act of 1996, the Family Educational Rights and Privacy Act, the Federal Privacy Act of 1974, and the Minnesota Government Data Practices Act.

I Accept

Date:

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