Momentum Network - Interest Form

Primary Email*

First Name*

Last Name*

Primary Phone*

What is your date of birth?*

Address Line 1*

Address Line 2

City*

ZIP / Postal Code*

State / Province*

Please enter in abbreviated format: TN, GA, etc.

What best describes your enrollment status?*

Currently enrolled in college

Currently accepted into college this semester or next

Received diploma/HiSet/GED

High School Student

Are you interested in going to college?

Yes

No

Do you graduate this year?

Yes

No

What College?

Other College:

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

What is your desired degree?

What is your estimated graduation date?

If you haven't started college yet, estimate 2 years for an Associate's, and 4 years for a Bachelor's degree (from start date).

What is your relationship status?*

Single

Divorced/Separated

Cohabitating with child's other parent

Dating

Married

Are you currently pregnant?*

Yes

No

How many children do you currently have?*

If pregnant, do not include current pregnancy in your total.

If over 3, how many?

Child 1's Birthdate

Child 2's Birthdate

Child 3's Birthdate

Do you have any children over the age of 12?*

Yes

No

Are you currently employed?*

Yes

No

What is your hourly rate? ($/hr)

Please enter the dollar ($) amount you are paid per hour.

What are your estimated weekly earnings?

If you aren't sure, just multiply your hourly rate by your total weekly hours worked.

What kind of support are you interested in? (Check all that apply)*

How can we help? Check all that you have some interest in:

Safe, affordable housing

Friends/Community with other moms in college

Help making a pregnancy decision

Reliable, affordable quality childcare

Support navigating next steps/making a plan to overcome obstacles to completing college

Financial guidance, including navigating Scholarships, Loans, and Public Assistance

Growing as a Christian or exploring faith

Required volunteer hours

Parenting Help

Are you interested in living in our residential development program?*

Yes

No

How did you hear about Momentum?*

Which school referred you?

Other:

What agency referred you?

Other:

Interest Form

Please schedule a meeting with our coaching team so that we can learn a little more about you and how we can help you achieve your goals.