Program Application

To complete the next step in determining your eligibility for our programs, complete the below application and submit your $100 non-refundable application fee.

Once we’ve received your application and payment, we’ll contact you to begin the next step in the process.

If you have any questions as you complete the application, please contact Emily Lourim at emily@onmyownofmi.org or (248) 649-3739 x 221.

Program Application

Applicant Name(Required)

First Last

Applicant Date of Birth(Required)

Applicant Gender Identity(Required)

Applicant Pronouns

Applicant Racial Identity(Required)

Applicant's Current Grade Level(Required)

Applicant's Current School (if applicable)

Applicant's Developmental Disability(Required)

Applicant's Current Mental Health Diagnoses (write n/a if none)(Required)

Applicant's Current Chronic Health Diagnoses (write n/a if none)(Required)

Applicant's Allergies or Dietary Restrictions (write n/a if none)(Required)

Applicant's Legal Guardian (write n/a if self)(Required)

Applicant's Financial Power of Attorney (write n/a if none)(Required)

Applicant's Medical Power of Attorney (write n/a if none)(Required)

Applicant's Email Address

Applicant's Cell Phone Number

Applicant's Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

First Emergency Contact's Name(Required)

First Last

First Emergency Contact's Relationship to Applicant(Required)

First Emergency Contact's Email Address(Required)

First Emergency Contact's Cell Phone Number(Required)

First Emergency Contact's Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Second Emergency Contact's Name

Second Emergency Contact's Relationship to Applicant

Second Emergency Contact's Email Address

Second Emergency Contact's Cell Phone Number

Second Emergency Contact's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Programs I'm interested in (select all that apply)(Required)

Independence Prep

Independence College

Independent Living

I heard about On My Own of Michigan from(Required)

I affirm the applicant does not need 1:1 supervision(Required)

Yes

I affirm the applicant can independently manage their daily living activities (eating, using the restroom, hygiene)(Required)

Yes

I affirm the applicant has no history of aggression or harm to themselves or others in the last year(Required)

Yes

Pay $100 Application Fee