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English
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Applicant & Family Member Information
Please fill out the following information as accurately as possible.
Child's Name:
Nickname:
Birthdate:
MM
/
DD
/
YYYY
Gender:
Male
Female
Child's Health Coverage:
CHP+
Private
Other
Medicaid
Tricare
None
Other:
Medicaid Number:
Doctor's Name:
Clinic's Name:
Dentist's Name:
Clinic's Name:
Preferred Hospital:
Evans Army
Memorial North
St. Francis North
Memorial Central
Penrose Main
UC Children's
Child's Race (check all that apply):
American Indian/Alaskan Native
Hawaiian/Pacific Islander
Asian
White
Black
Other
Other:
Hispanic:
Yes
No
English Proficiency:
Proficient
Little
Moderate
None
Other Language Spoken by Child:
Other Language Proficiency:
Proficient
Moderate
Little
Primary Adult
Your Name:
Nickname:
Birthdate:
MM
/
DD
/
YYYY
Gender:
Male
Female
Your Race (check all that apply):
American Indian/Alaskan Native
Hawaiian/Pacific Islander
Asian
White
Black
Other
Other:
Hispanic:
Yes
No
English Proficiency:
Proficient
Little
Moderate
None
Other Language Spoken by You:
Other Language Proficiency:
Proficient
Moderate
Little
Highest Grade Completed:
No School
Associates Degree
Not a Graduate
Vocational Degree
Graduate/GED
Bachelor's Degree
Some College
Master's Degree
Employment Status:
Full-time
Unemployed
Part-time
Job Training
Seasonal
Retired or Disabled
Your Relationship to Child:
Biological/Adopted/Step Child
Foster Child
Grandchild
Other
Other Relative
Other Relationship:
Do you have legal custody of this child?
Yes
No
Please check all that apply to you:
Adult lives in household
Provides financial support
Teen parent
Secondary or Other Adult
Is there a secondary or other adult in the home?
Yes
No
Other Adult Name:
Nickname:
Birthdate:
MM
/
DD
/
YYYY
Gender:
Male
Female
Race (check all that apply):
American Indian/Alaskan Native
Hawaiian/Pacific Islander
Asian
White
Black
Other
Other:
Hispanic:
Yes
No
English Proficiency:
Proficient
Little
Moderate
None
Other Language Spoken:
Other Language Proficiency:
Proficient
Little
Moderate
Highest Grade Completed:
No School
Associates Degree
Not a Graduate
Vocational Degree
Graduate/GED
Bachelor's Degree
Some College
Master's Degree
Employment Status:
Full-time
Unemployed
Part-time
Job Training
Seasonal
Retired or Disabled
Relationship to Child:
Biological/Adopted/Step Child
Foster Child
Grandchild
Other
Other Relative
Other Relationship:
Does this adult have legal custody of this child?
Yes
No
Please check all that apply to this adult:
Adult lives in household
Provides financial support
Teen parent
Additional Adults in Home
Are there additional adults in the home?
Yes
No
Adult's Name:
Birthdate:
MM
/
DD
/
YYYY
Gender
Male
Female
Relationship to Child:
Adult's Name:
Birthdate:
MM
/
DD
/
YYYY
Gender
Male
Female
Relationship to Child:
Additional Children in Home
Are there additional children in the home?
Yes
No
Name:
Birthdate:
MM
/
DD
/
YYYY
Gender:
Male
Female
Name:
Birthdate:
MM
/
DD
/
YYYY
Gender:
Male
Female
Name:
Birthdate:
MM
/
DD
/
YYYY
Gender:
Male
Female
Name:
Birthdate:
MM
/
DD
/
YYYY
Gender:
Male
Female
Name:
Birthdate:
MM
/
DD
/
YYYY
Gender:
Male
Female
Name:
Birthdate:
MM
/
DD
/
YYYY
Gender:
Male
Female
Name:
Birthdate:
MM
/
DD
/
YYYY
Gender:
Male
Female
Family Questions
Parental Status
Single
Two Parent
Homeless Family
Yes
No
Active Duty Military
Yes
No
SNAP
Yes
No
WIC
Yes
No
Address & Contact Information
Living Address:
When did you start living at this address?
Is your mailing address the same?
Yes
No
Mailing Address:
Phone:
Type:
Cell
Home
Work
Belongs To:
Mom
Dad
Other
Text Opt In:
Yes
No
2nd Phone:
Type:
Cell
Home
Work
Belongs To:
Mom
Dad
Other
Text Opt In:
Yes
No
Emergency Contacts
Contact Name:
Relationship to Child:
Phone:
Address:
Contact Name:
Relationship to Child:
Phone:
Address:
Certification:
I certify that this information is true. If any part is false, my participation in this agency's programs may be terminated and I may be subject to legal action. I also understand that the information in this application will be held in strict confidence within the agency and is accessible to me during normal business hours.
Signature:
Clear
Date:
03
/
29
/
2025
SUBMIT FORM
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