Christ-centered homes & programs for pregnant and parenting young moms.

Ruth Harbor Admission Application

Download a printable copy of the full PDF application form.


Specify Program


Applicant Information (Birthmother)

This field must be a valid email address.

Education Information

Residents who have not received their high school diploma or GED are encouraged to enroll, with House Parent assistance, in the G.E.D. program at the local community college or attend middle or high school.


Family Information

Father or Father-Figure of Applicant

This field must be a valid email address.

Mother or Mother-Figure of Applicant

This field must be a valid email address.

Relationships

Do you feel like the following people listen to what you have to say?


Employment Information

Previous Employment (Please list previous employers & length of employment at each)


Legal


Spiritual


Medical Information


Maternity Health [For Maternity Applicants: If applying for the New Mom/Mother-Child Program, skip to FINANCIAL INFORMATION]


Financial Information

If you are insured or covered under an individual or family policy, please complete the following:

If you do not have insurance, you may be eligible for Title IXX (Medicaid) or other state government coverage. Please bring the following when you arrive for check in at Ruth Harbor. We have a copier so you can bring the original documents if you want.
-Social Security Card
-Copy of Birth Certificate


Father of the Baby Information


Support System


Child’s Information [Complete if applying for the Mother-Child Program; If applying for Maternity Program, skip ahead to SIGNATURES below]


Child’s Medical Information


Child’s Legal Information [Complete if applying for the Mother/Child Program]

By submitting below, I verify that all information is correct and accurate on this application.

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Christ-centered homes & programs
for pregnant and parenting young moms.

Ruth Harbor
534 42nd Street
Des Moines, IA 50312
Phone: 515-279-4661
Fax: 515-633-2157
M-F 8:30 AM-5 PM
info@ruthharbor.org