Fill out the form below or print and mail completed application to:
P.O Box 787
415 S. Queen Street
Lancaster, PA 17608-0787

We will call to schedule an interview.

If you have any questions while completing the application—or after you have mailed it back to us—please call and ask for the Program Director or Executive Director. 717.396.9130

• First Name*
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• Last Name*
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• Birthdate*
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• Address*
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• City*
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• State*

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• Zip Code*
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• Email*
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• Phone*
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• Social Security #*
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• Marital Status*

  Single

  Divorced

  Separated

  Other
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• Living Arrangements*

  Self

  Parents

  Relatives

  Other
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• Cost of Housing Per Month*
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• List household members and their relationship to you*
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• Means of Financial Support per month
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• Are you working?*

  Yes

  No
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• Parents*
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• Public Assistance*
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• Child Support*
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• Food Stamps*
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• WIC*
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• Employment*
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• Other*
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• Please upload a photo of your last two pay stubs*Upload
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• Educational Plans
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• List any degrees, certificates or diplomas you have already received*
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• Where are you currently attending school?*
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• If not currently attending, where do you plan to enroll or attend?*
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• After completing your schooling, what kind of job would you like?*
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• Expected beginning date of classes*
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• Expected completion or graduation date*
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• List any work experience or special training:*
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• Child Information
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• Name*
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• Birthdate*
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• Name*
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• Birthdate*
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• Name*
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• Birthdate*
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• Name*
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• Birthdate*
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• Why do you want to become part of our program at Mom’s House?*
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• The following information is needed for an annual report with the Commonwealth of PA to conform with anti-discrimination laws. You are not required to fill this out

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• *	Caucasian	African American	Hispanic	Asian/Pacific	Other
  Parent's Race
  Child's Race
  Child's Race
  Child's Race
  Child's Race

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• Apply Now
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