Independence Prep Application

To complete the next step in determining your eligibility for Independence Prep, please review the qualification criteria and vaccination requirements of the program, complete the below application and submit your $50 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 Director of Education Emily Lourim at emily@onmyownofmi.org or (248) 649-3739 x 221.

Independence Prep Application

Step 1 of 4

Applying for:*
Student First + Last Name*
Student Date of Birth*
MM slash DD slash YYYY
Student Gender Identity*
Student Pronouns*
Student Grade Level*
Student School Name:
Student Developmental Disability*
Student Mental Health Diagnosis (write n/a if none)*
Student Chronic Health Diagnosis (write n/a if none)*
Can Student Take Medication Independently?
- Yes
- No
Student Allergies or Dietary Restrictions (write n/a if none)*
Does Student Currently Have an IEP, 504 Plan or Annual Plan?*
- Yes
- No

Student Address*
Street Address Address Line 2 City State ZIP
Student Email Address*
Student Cell Phone Number*
Emergency Contact #1 First + Last Name*
Emergency Contact #1 Relationship to Student*
Emergency Contact #1 Address*
Street Address Address Line 2 City State ZIP
Emergency Contact #1 Email Address*
Emergency Contact #1 Cell Phone Number*
Emergency Contact #2 First + Last Name
Emergency Contact #2 Relationship to Student
Emergency Contact #2 Address
Street Address Address Line 2 City State ZIP
Emergency Contact #2 Email Address
Emergency Contact #2 Cell Phone Number
Legal Guardian First + Last Name (write n/a if self)*
Financial Power of Attorney First + Last Name (write n/a if none)*
Medical Power of Attorney First + Last Name (write n/a if none)*

Most Recent Teacher or Social Worker First + Last Name*
Teacher or Social Worker Email Address*
Teacher or Social Worker Phone Number*

I attend a Title I school + am eligible for free lunch
I would like to be considered for the McFawn Family Scholarship Fund (open to students attending a Title 1 school and eligible for free lunch)
I heard about Independence Prep from:

Pay $50 Application Fee