Pre-Application Form

Parent First Name

Parent Last Name

Home Phone Number

Mobile Phone

Best number to reach you by

Email Address

Preferred method of contact: call/ text/ email

Date of Birth (mm/dd/yyyy)

Do you currently have a child of eligible age? Do you currently have a child of eligible age? Yes No

Street Address

City

Zip Code

Child's First Name

Child's Last Name

Child's Date of Birth (mm/dd/yyyy)

Parent Type Parent Type SPF (Single Parent Father Figure) SPFP (Single Parent Father w/Partner) SPM (Single Parent Mother Figure) SPMP (Single Parent Mother w/Partner) TPF (Two Parent Family)

Homeless Homeless Yes No

Has this child been in or is currently in foster care? Has this child been in or is currently in foster care? Yes No

Have you received any financial assistance in the last year? Have you received any financial assistance in the last year? Yes No

Supplemental Security Income (SSI) Supplemental Security Income (SSI) Yes No

Temporary Assistance for Needy Families (TANF) Temporary Assistance for Needy Families (TANF) Yes No

SNAP-3 Squares SNAP-3 Squares Yes No

Estimated annual income

Number of children in your family:

Number of adults in your family: