1:1 Coaching Application

To start your 1:1 coaching, please complete the below application and submit your $50 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 Director of Education Emily Lourim at emily@onmyownofmi.org or (248) 649-3739 x 221.

Program Application

Program I'm Applying For(Required)

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 Diagnosis (write n/a if none)(Required)

Applicant's Current Chronic Health Diagnosis (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(Required)

Applicant's Cell Phone Number(Required)

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

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

Make $50 Deposit