A network of support & resource center for Iowa Fathers
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Type of Service Requesting: (Check all that apply)
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Monetary
Employment
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Addiction Counseling
Child Supplies
Support-Group Counseling
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Number of children you have and on their way
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Ages of each child:
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Child and Mother's full name that you are requesting services for:
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Briefly explain your situation and reason for requesting a service.
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Employer(s) and Dates of employment for the last 5 years
Annual income:
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Education (List all starting with High School Diploma/GED along with the year)
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Have you ever been charged or convicted of a felony?
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No
Have you ever been charged or convicted of a misdemeanor?
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No
Has DHS ever accused you of child abuse or neglect?
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No
If you answered YES to any of the above questions, please explain: (include dates and charges)
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How did you hear about Paternal Guardians of Iowa?
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List 3 references, phone number, and relationship to you.
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Enter initials if you understand the following:
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Paternal Guardians of Iowa does not sell, trade, or otherwise transfer or disclose your personally identifiable information to outside parties. This does not include trusted third parties who assist us in operating our website, conducting our business, or servicing you, so long as those parties agree to keep this information confidential. We may also release your information when we believe release is appropriate to comply with the law, enforce our site policies, or to protect our or others’ rights, property, or safety. However, we reserve the right to provide non-personally identifiable visitor information to other parties for marketing, advertising, or other uses.
Enter initials if you understand the following:
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Once you have returned this form back to Paternal Guardians of Iowa, we will review it at the next board meeting (board meetings happen on the first Monday of each month). A vote will take place on how to further proceed, which may require you to be interviewed by the board. After the interview, the board will then decide if your application has been accepted and the extent of assistance we will be providing. Once a decision has been made you will be contacted and notified.
By signing below, you are stating that you agree and understand to the terms stated. To the best of your knowledge, all information provided is completely true and accurate. Failure to disclose or falsifying information will result in your application being denied.
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