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Enrollment Application

Thank you for your interest in joining Single Mothers Outreach (SMO). Once we receive your completed enrollment form, we will contact you to schedule an appointment to hear your story, discuss your needs and share the programs and services SMO offers. You must be a resident of Santa Clarita Valley, including the communities of Acton, Agua Dulce, Castaic, Canyon Country, Newhall, Saugus, Stevenson Ranch, Valencia, and Val Verde. All programs and services are offered free of charge. We look forward to meeting you!

Single Mothers Outreach will not discriminate based upon disability, religion, race, color, national origin, gender, age, or sexual preference.

* Required

Errors

What day(s) of the week can you meet with SMO?

Today's Date *

PERSONAL INFORMATION

First Name *

Last Name *

Birth Date *

Address Line 1 *

Address Line 2

City *

State *

ZIP Code *

Home Phone Number
( ) - ext.

Cell Phone Number
( ) - ext.

Primary Email Address

What is your marital status? *

Single never married

Separated/Divorced

Widowed

What is your race? *

White/Caucasion

Black/African Amer

Hispanic/Latino

Asian

Pacific Islander

Native American

Other

Please check if you are currently enrolled in college or trade school

How did you hear about us? *

If indicated "Other", please explain

HOUSING INFORMATION

Housing Status *

Rent

Own

Homeless with roof

Homeless without roof

Housing Type *

Apartment

Duplex

Home

Mobile/Trailer

Room

Other

Rent/House payment (per month) *

INCOME SOURCES

Do you currently receive child support? *

Yes

No

If you indicated yes, how much do you receive MONTHLY? (i.e. $600)

Do you receive alimony? *

Yes

No

If you replied yes, how much do you receive MONTHLY? (i.e. $600)

Are there any issues that interfere with your ability to maintain employment? *

Yes

No

If you replied yes above, please explain.

Please list all MONTHLY income sources. Use a separate line for each source. (i.e. Job: $2000) *

Annual Income *

0-14,999

15,000-20,999

30,000-49,999

50,000-59,999

60,000 +

PERSONAL HISTORY

Do you have a history of substance abuse? *

Yes

No

If you answered yes above, do you feel this is a current issue? *

Yes

No

Have you been convicted of a crime? *

Yes

No

Have you had involvement with Children's Services? *

Yes

No

Have you experienced emotional or physical abuse? *

Yes

No

What resources are you looking for? *

What are your goals, if any? *

EDUCATION COMPLETED

Please check highest level education achieved. *

1-8th Grade

HSD-12th

GED

Some College

College Degree

Disabled? *

Yes

No

If you indicated yes, who in your family is disabled?

You

Child

Both

What day(s) of the week can you meet? (Check all that apply)

Monday *

Tuesday

Wednesday

Thursday

Saturday

What time of day can you meet?

Morning

Afternoon

Evening (weekdays only)

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Enrollment Application