Eligibility Application
Primary Caregiver General Information
Date
-
Month
-
Day
Year
Date
Full Name:
*
First Name
Middle Name
Last Name
Birth Date:
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Phone:
*
-
Area Code
Phone Number
E-mail:
*
Language:
Gender:
Male
Female
Prefer Not to Say
Race:
Asian
Bi-racial/Multi-racial
Black
Caucasian
Native American
Pacific Islander
Other
Unspecified
Education Level
Bachelor or Advanced Degree
College Degree or Training School Certificate
ESL
GED
High School Graduate
No High School
Some College / Vocational / Associates Degree
Highest Grade Completed _______
Unknown
Are you receiving HEAP benefits?
*
Please Select
Yes
No
Are you receiving WIC?
Yes
No
Are you receiving Food Stamps / SNAP?
Yes
No
Employment Status:
Employed Full-Time
Employed Part-Time
Employed Seasonally
Retired or Disabled
Homemaker
Self Employed
Full-Time Training
Part-Time Training
Job Training / School PT
Farmer
Migrant Farm Worker
Seasonal Farm Worker
Unemployed
Unknown
Employer Name / School Name
United States Military Status:
Veteran
Active Duty
Not a member
Parent/Guardian Best Descriptor:
Mother
Father
Grandparent
Other Relative
Foster Parent
Other
Family Structure:
Single Parent
Two Parent
Number in Family:
Number in Household:
Marital Status:
Married
Divorced
Separated
Widowed
Single
Other
Family Type:
Single Parent Male
Single Parent Female
Two Parent Household
Two Parent Unmarried
Other
Disabled?
Yes
No
Medical Insurance:
BCBS
Medicaid / CHIP
State Funded
Private
None
Other
Current Housing:
Own
Rent
Homeless
Other
Comments:
Is there a Secondary Caregiver?
Yes
No
Signature
*
CAP Staff Signature
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Eligibility Application Con't
Secondary Caregiver (Skip to page 3 if there is no secondary caregiver)
Full Name:
First Name
Middle Name
Last Name
Birth Date:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
-
Area Code
Phone Number
Email:
example@example.com
Language:
Gender:
Male
Female
Prefer Not to Say
Race:
Asian
Bi-Racial/Multi-Racial
Black
Caucasian
Native American
Pacific Islander
Other
Unspecified
Save
Submit
Education Level
Bachelor or Advanced Degree
College Degree or Training School Certificate
ESL
GED
High School Graduate
No High School
Some College / Vocational / Associates Degree
Highest Grade Completed _______
Unknown
Employment Status:
Employed Full-Time
Employed Part-Time
Employed Seasonally
Retired or Disabled
Homemaker
Self Employed
Full-Time Training
Part-Time Training
Job Training / School PT
Farmer
Migrant Farm Worker
Seasonal Farm Worker
Unemployed
Unknown
Employer Name / School Name
United States Military Status:
Veteran
Active Duty
Not a member
Medical Insurance:
BCBS
Medicaid / CHIP
State Funded
Private
None
Other
Current Housing:
Own
Rent
Homeless
Other
Signature:
*
CAP Staff Signature:
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Child Application
Name
First Name
Middle Name
Last Name
Birth Date:
Gender:
Male
Female
Prefer Not to Say
Race:
Asian
Bi-Racial/Multi-Racial
Black
Caucasian
Native American
Pacific Islander
Other
Unspecified
Primary Language:
Translator Needed:
Yes
No
School District:
Medical Office:
Date of Last Physical:
Dentist Office:
Date of Last Dental Visit:
Medical Insurance:
BCBS
Medicaid / CHIP
State Funded
Private
None
Other
Relation to Primary Caregiver:
Relation to Secondary Caregiver:
Eligibility Information (Please select all that apply):
Chronic Health Concern /At Risk Pregnancy
Lacks Child Care
Mental Health
Child Protective Services
No Linkage to Health Services
Homeless
Domestic Violence
Current Teen Oarent
Caregiver Further Education
Disability Status (IEP IFSP)
Non-English Speaking (LEP)
Basic Needs are Not Met
Parent in Prison
Substance Abuse
Foster Care / Kinship Care
Emergency Contacts (Not Primary or Secondary Caregiver):
Name
Relationship
Phone Number
1
2
3
4
Additional Family Members:
Name
DOB
1
2
3
4
5
6
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