Momentum Network · Member Interest Form

Contact Information

Name

*

First Name

Last Name

Email

*

Phone

*

Organization/Employer

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

My primary goal:

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(Pregnant or Single Parent) Motivated to Complete College

(Volunteer/Support Network) who wants to help single moms &/or kids

Volunteer Interest(s):

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Sharing professional skills/experience

Christian Discipleship

Childcare

Cooking for Kids & Moms

Planning events

Ambassador/Liaison

Other (list below)

Other volunteer interest:

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Which best describes you?

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If you are enrolled in college, but on maternity leave or just taking a 1-semester break, select the first option. Our definition of single is either unmarried or divorced or widowed AND not living with a romantic partner. A parent who is dating is welcome to apply.

Pregnant or Single Parent currently enrolled in college

Pregnant or Single Parent currently accepted into college this semester or next, but not enrolled yet

Single Parent highly interested in college. Received diploma/HiSet/GED

Pregnant High School Student

Other Support Needed:

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Name (s)& Age(s) of Child(ren):

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Input due date if you are pregnant

College

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Please select the college where you are enrolled (or will be enrolled next semester)

Other College:

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Your college may not be an approved institution yet, but go ahead and let us know where you go & we'll explore the possibilities.

Please describe your college plans:

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Include the steps you've completed towards college enrollment & steps you still need to take in as much detail as possible.

Tell us how you would like to get involved:

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Scholar Village Living & Learning Community

ScholarVillage

Living & Learning Program

Live & learn in a community with other single moms in college. Residents will live close to campus in their own 2 bedroom apartment with childcare available onsite or nearby.

Are you interested in living in our residential development program?

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We will send you more information if so.

Yes

No

How did you hear about MOMentum?

*

Who can we thank for referring you?

Would you like to make a gift today to help moms & children build a better future?

*

I'd love to!

Not yet

Amount

$100

$50

$25

$

Donation Schedule

Reminder

If you cannot submit the application, scroll up to make sure that you have completed all required fields.

Do you want to be a part of the network empowering single moms & their children to move beyond survival mode to thriving? If so, keep going to sign up below. We'll contact you to share more based upon your goals.