Christian's Manor-Inquiry

Please fill out the Inquiry Sheet. CM staff will reach out to you regarding program availability.

Date

First Name

Middle Name

Last Name

Date of Birth

mm/dd/yyyy

E-Mail Address

Phone Number

Phone

Street Address

Address Line 2

City

State

Zip Code

Describe your current living situation.

Are you 18 years or older?

Are you a single parent to a child(ren) under 16?

Do you have an income at or below poverty level?

Are you currently employed at least part-time?

Employer Name

Do you have a GED or HS Diploma?

Are you currently attending school?

Campus Attending

Have you already completed a bachelor's degree?

Are you currently pregnant?

How many children do you have?

Do you have at least 50% custody?

Child 1 DOB

Child 2 DOB

Child 3 DOB

Child 4 DOB

Child 5 DOB

How did you hear about our program?