New Member Interest Form

New Member Interest Form

Thank you for your interest in C4K! We work with residents of the City of Charlottesville or Albemarle County, Virginia who are in 6th-12th grade and are from households with income less than 80% of the region's Median Family Income. Please fill out the information below and we will follow up to answer questions, confirm interest / eligibility, and plan out next steps.
Member Information
Potential Member Full Name *
Contact Name *
The person we can contact to discuss eligibility for and interest in C4K.
Contact Relationship to Potential Member *
Contact Mobile Number *
Please enter a valid phone number.
Contact Email Address
example@example.com
Contact notification preference. *

Text Email
Do you authorize C4K to text message the number provided? *

Eligibility
Grade *
Upcoming grade if we're in the Summer
What school do you go to? *
Upcoming school if we're in the Summer.
In which locality do you live? *
If other, please provide school.
If other, please provide locality.
How many people (including member) live in the household? *
Is your household income less than $67,100 per year? *
Include ALL sources of income, such as child support, alimony, Social Security, welfare payments, dividends or interest, rental income, unemployment, retirement income, pensions, veteran payments, regular contributions from persons not living in the household, royalties, or other cash income.
Is your household income less than $75,500 per year? *
Include ALL sources of income, such as child support, alimony, Social Security, welfare payments, dividends or interest, rental income, unemployment, retirement income, pensions, veteran payments, regular contributions from persons not living in the household, royalties, or other cash income.
Is your household income less than $83,850 per year? *
Include ALL sources of income, such as child support, alimony, Social Security, welfare payments, dividends or interest, rental income, unemployment, retirement income, pensions, veteran payments, regular contributions from persons not living in the household, royalties, or other cash income.
Is your household income less than $90,600 per year? *
Include ALL sources of income, such as child support, alimony, Social Security, welfare payments, dividends or interest, rental income, unemployment, retirement income, pensions, veteran payments, regular contributions from persons not living in the household, royalties, or other cash income.
Is your household income less than $97,300 per year? *
Include ALL sources of income, such as child support, alimony, Social Security, welfare payments, dividends or interest, rental income, unemployment, retirement income, pensions, veteran payments, regular contributions from persons not living in the household, royalties, or other cash income.
Is your household income less than $104,000 per year? *
Include ALL sources of income, such as child support, alimony, Social Security, welfare payments, dividends or interest, rental income, unemployment, retirement income, pensions, veteran payments, regular contributions from persons not living in the household, royalties, or other cash income.
Is your household income less than $110,700 per year? *
Include ALL sources of income, such as child support, alimony, Social Security, welfare payments, dividends or interest, rental income, unemployment, retirement income, pensions, veteran payments, regular contributions from persons not living in the household, royalties, or other cash income.

Additional Information / Questions
Do you have any additional information you would like to provide or questions for C4K?
Should be Empty:

New Member Interest Form

Member Information

Eligibility

Additional Information / Questions