LifeHope Childcare Center Application

PLEASE NOTE: WE HAVE LIMITED CHILDCARE SPOTS IN OUR ROOMS. YOU WILL BE CONTACTED WHEN A SPOT OPENS, DEPENDING ON WHEN YOU APPLIED.

This form is for single moms who are interested in becoming part of the LifeHope Childcare program. This track includes worship attendance, life coaching meetings, classes, and more.

Your name *

Last name

Email address *

Preferred Name/ Nick Name *

Phone Number *

Phone type

By checking this box, you agree to receive SMS text messages from Northland Church at the phone number provided.

Yes, I agree to receiving text messages from Northland/ Mercy Road regarding my application or the childcare program.

Address *

Country

Street address

Apt/unit/box (optional)

City

State

Postal code

Driver's License Number *

Driver's License State *

Last four of your social security number *

Birthday *

Primary Race *

Ethnicity *

Current Housing Status *

Relationship Status *

Living with child's father/ significant other

Single, not living with child's father/ significant other

Married

Divorced

Engaged

Widowed

Dating, Exclusive Relationship

Married, but separated

What is your form of transportation?

a car that I own or make payments on

public transportation including the bus or Uber

borrow a friend or family member's car

Highest Level of Education Attained *

What school did you attend for highest level of education? *

Are you currently enrolled in school? *

Occupation/ Employer *

Employment Status *

What is your dream job? *

What would it take to get there? *

Do you have a faith-based organization? *

How did you hear about LifeHope Childcare? *

What is the name of your faith-based organization, if other than Northland?

Number of children in household *

min: 1 / max: 8

Child 1 First and Last Name *

Child 1 Gender *

Child 1 Date of Birth *

Child 2 First and Last Name

Child 2 Gender

Child 2 Date of Birth

Child 3 First and Last Name

Child 3 Gender

Child 3 Date of Birth

Child 4 First and Last Name

Child 4 Gender

Child 4 Date of Birth

What is your monthly income after taxes? Please provide an approximate amount. If it is not consistent, please give us your best guess. You will be asked for proof of income. *

I understand that I will be required to submit my two most recent bank statements. This is required of all potential clients that we may serve, whether financially or through childcare.

Yes, I will submit two recent bank statements when requested.

I do not have a bank account, but understand it will be a requirement to open a bank account if I am accepted into the LifeHope program.

Part of our program requires a weekly Advocate Meeting to work on goals. Would you be able to commit to a 45 minute meeting each week to work on goals? *

Please explain your answer. If yes, explain how. If no, not interested, or unsure, explain why. *

What are some obstacles preventing you from achieving this? *

What is something you hope to accomplish within the next year? *

Our childcare center is open Monday - Friday, 7:15 a.m. until 6:00 p.m. What hours is childcare needed? *

Reference #1 Name and Phone Number *

Release of Information

When you request or receive services from Northland LifeHope, we collect information about you and your household and enter it into a secure system at Northland Church. This is an information system that helps us to better understand the needs of our communities, to improve service delivery to you and to evaluate the effectiveness of services provided.

• I understand that limited specific information about my case, including medical, mental health or substance abuse history may be shared with other faith-based providers, non-profits, mental health professionals, and government organizations throughout Central Florida to facilitate additional services that may benefit me or my child/children.

Your release of information authorization is valid for three (3) years from the date of this document. You may cancel this authorization at any time by written request, but the cancellation will not be retroactive.

Reference #2 Name and Phone Number *

I have read, understand, and agree to the Release of Information stated above. I understand I may cancel this agreement at any time by written request, but the cancellation is not retroactive. *

I confirm and certify that information I have recorded is true and correct. I understand that Northland may verify information on this application and that deliberate misrepresentation may subject me to denial of services. *

Is there anything you would like us to know that was not covered in this application?

Northland Church
hello@northlandchurch.net
407-949-4000