Apply Online Apply Online Interested in Mary’s Song? Send us your information so we can contact you. Personal Information Last Name First Name Street Address Street Address Line 2 State / Province City Country Postal / Zip Code Phone Number Emergency Contact Name / Phone Number Birth Date Email Address Martial Status Martial StatusSingleMarriedDivorcedWidowed Gender GenderMaleFemale Are You Court Ordered? Are You Court Ordered?YesNo If Yes, State on what condition and when? What is the reason for applying? (Please be specific.) What is your current weight? Are you pregnant? Are you pregnant?YesNo What is your height? Do you have children? Do you have children?YesNo If so, how many weeks are you pregnant? What are your plans for children during your stay at Mary's Song? How many children do you have? If yes, please list all medications you are taking. Are you taking medications? Are you taking medications?YesNo What drugs are you currently using? How often do you use? When was the last time you used? How long have you been using? Are you currently drinking alcohol? How often do you drink? When was the last time you drank? How long have you been drinking? Do you have any medical issues? (Please list any current diagnoses and how long you have been diagnosed.) Have you had, or been tested for COVID-19 in the past 30 days? Have you had, or been tested for COVID-19 in the past 30 days?YesNo Have you been fully vaccinated for Covid-19? Have you been fully vaccinated for Covid-19?NoYes Do you have any physical disabilities that need special accommodations? Have you ever tested positive for COVID? Have you ever tested positive for COVID? NoYes When did you test positive? Submit Application