Documento
Please fill out application completely
Parent & Household Information
Primary Parent/Guardian First Name: Last Name: Relationship to child: Parent Step Parent Guardian Race: Black White Asian Hawaiian/Pacific Separated Widowed Hispanic US Indian/Alaskan Sex: Male Female Non- Hispanic Marital Status:Single Married Divorced Date of Birth: Social Security : Are you disabled? Are you a Student? Yes Yes No No Other: Foster Parent Primary Language Spoken: Secondary Parent/Guardian (ONLY IF IN HOUSEHOLD) First Name: Last Name: Relationship to child: Parent Step Parent Guardian Race: Black White Asian Hawaiian/Pacific Separated Widowed Hispanic US Indian/Alaskan Sex: Male Female Non- Hispanic MaritalStatus: Single Married Divorced Date of Birth: Social Security : Are you disabled? Are you a Student? Yes Yes No No Other: Foster Parent
If Yes how many credit hours? Are you employed? Employer Name: Work Phone: Number of hours worked per week? Gross Earnings: Hourly Rate: Salary: Weekly Bi-weekly Monthly Semi-Monthly Yes No
If Yes how many credit hours? Are you employed? Employer Name: WorkPhone: Number of hours worked per week? Gross Earnings: Hourly Rate: Salary: Weekly Bi-weekly Monthly Semi-Monthly Yes No
Does anyone in the house receive: NO Child Support Alimony TANF/AFDC Veteran's Benefits Retirement Social Security Residential Address: Address: City: County: Phone Number: YES Amount
(Please provide monthly amount and name of family member receiving income) Name SSIUnemployment Worker's Comp Interest/Dividends
Relative Care Giver Funds (RCG)
NO
YES
Amount
Name
Other Mailing Address: (If different than Residential Address) Address: Zip Code: City: E-mail: Alternate Number: Zip Code:
Please fill out child(ren)s information on back side of application. Once completed please submit application to your local coalition office listed below:Charlotte Office DeSoto Office Hardee Office Highlands Office 3028 Caring Way, Suite 4 4 West Oak Street, Suite H 324 N. 6th Avenue 209 N. Ridgewood Drive Port Charlotte, FL 33952 Arcadia, FL 34266 Wauchula, FL 33873 Sebring, FL 33870 Phone: (941) 255‐1650 Phone: (863) 494‐5233 Phone: (863) 767‐1002 Phone: (863) 314‐9213 Fax: (941) 255‐5856 Fax: (863) 494‐5291 Fax: (863) 767‐1007 Fax: (863) 314‐4480
“Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.” Margaret Mead
Revised 08-21-08
PLEASE LIST ALL CHILDREN IN THE HOUSEHOLD
Child(ren) Information:
First Name: Gender: Race: Female Black Male White SS # : Asian US Indian/Alaskan Last Name: Date of Birth: Are ScholarshipServices needed for this child? Hawaiian/Pacific Hispanic Non-Hispanic Yes No
Are there any special needs for this child? If so please explain:
First Name: Gender: Race: Female Black Male White SS # : Asian
Last Name:
Date of Birth: Are Scholarship Services needed for this child? Yes No
US Indian/Alaskan
Hawaiian/Pacific
Hispanic
Non-Hispanic
Are there any special needsfor this child? If so please explain:
First Name: Gender: Race: Female Black Male White SS# : Asian
Last Name:
Date of Birth: Are Scholarship Services needed for this child? Yes No
US Indian/Alaskan
Hawaiian/Pacific
Hispanic
Non-Hispanic
Are there any special needs for this child? If so please explain:
First Name: Gender: Race: Female Black Male White SS # :...
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