Apply to the RootedPath Program

SECTION ONE: APPLICANT INFORMATION

What is your legal name? *

First

Middle

Last

What is your preferred name?

List any other last names you have gone by:

Do you currently have a stable place to live? *

Yes
No

What is your current address? *

Address Line 1

Address Line 2

City

State

Zip Code

Previous Address (last place of residence) *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Email

Confirm Email

Phone *

Alternative Phone *

List alternate number where you can be reached,

Date of Birth: *

Place of Birth (City, State) *

Do you have a social security card? *

Yes
No

Do you have a drivers license? *

Yes
No

Gender *

Male
Female

Ethnicity *

Hispanic or Latino
Not Hispanic or Latino

Race: *

What is your religious preference? (select one) *

Briefly describe your religious beliefs: *

SECTION TWO: REFERRAL INFORMATION

Were you referred to us? *

Name of referring agency or church:

Name of referring person *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Best Contact Information (email or phone number required) *

Please provide either an email address or a phone number.

Relationship to referring person: *

SECTION THREE: FAMILY INFORMATION

List your parent's names and cities of residence. *

Do you have siblings?

Yes
No

List your sibling's names, ages, and cities of residence. *

Describe your relationship with your parents and siblings: *

Do you have children?

Yes
No

List your children's names, ages, and cities of residence. *

List names, cities of residence, and relationships with other supportive relatives *

SECTION FOUR: BACKGROUND

Were you ever placed in the foster care system? *

Describe your personal experience in the foster care system. (Include your age at time of placement, placement locations, and any other details that will help us understand your experience.) *

What is your highest level of education completed: *

List other education completed: *

Are you currently enrolled in school?

Yes
No

What is the name of the school you are attending? *

What year are you in? *

Are you currenly employed?

Yes
No

Place of employment *

Name of supervisor *

First

Last

What is your position? *

What is your hourly pay? *

How long have you worked at your current job? *

Are you receiving assistance from other programs or organizations?

Yes
No

List all assistance being provided from other programs or organizations. (Include the organization name, contact person, and type of service being provided.)

Tell us about yourself. (Include special interests, education/career goals, and your hopes/dreams) *

SECTION FIVE: NEED

Please provide as much detail as you can about your specific needs.

What areas do you need assistance? (check all that apply) *

Give us details on how can we help you? (Include due dates, costs, etc.) *

How can we pray for you? (List problems, family issues, or praise for which we can pray.)

List any special or extenuating circumstances that you want us to consider when reviewing your application. *

SECTION SIX: COMMITMENT & ACKNOWLEDGMENT

Commitment *

I understand that I must dedicate my time to this program to achieve my academic, career, and personal goals. I am able and willing to do the work necessary to achieve my goals.

Acknowledgment *

I hereby declare that the information provided is true and correct. I also understand that any willful dishonesty may render for refusal of this application. I understand that the completion of this application does not guarantee support from Empower 7.

Acknowledgment of Empower 7’s Independence *

I understand that Empower 7 is an independent 501(c)(3) nonprofit organization. We are not part of any government agency or private child placement provider connected to the foster care system. Empower 7 operates independently and provides its own programs and services.

Signature of Applicant (type your full name) *

By typing your name in the space above, you are electronically signing Empower 7's RootedPath application.

Signature Date *

ROOTEDPATH APPLICATION

Application Process

ROOTEDPATH APPLICATION

SECTION ONE: APPLICANT INFORMATION

SECTION TWO: REFERRAL INFORMATION

SECTION THREE: FAMILY INFORMATION

SECTION FOUR: BACKGROUND

SECTION FIVE: NEED

SECTION SIX: COMMITMENT & ACKNOWLEDGMENT