2022-2023 Application for Educational Benefits
Free & Reduced Price School Meals
Parent Name
*
First Name
Last Name
Parent Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent Email
*
example@example.com
Parent Phone Number
*
Please enter a valid phone number.
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Number of Household Members who are infants, children, and students up to and including grade 12.
*
Please Select
1
2
3
4
5
6
7
8
9
Child 1
*
First Name
Middle Name
Last Name
What school does Child 1 attend?
*
Please Select
Not in School
Mesabi East Elementary
Mesabi East High School
School Readiness
Early Childhood
Grade Level of Child 1
*
Please Select
Not in School
Pre-K
K
1
2
3
4
5
6
7
8
9
10
11
12
Date of Birth for Child 1
*
/
Month
/
Day
Year
Date
Is Child 1 a foster child?
*
Yes
No
Child 2
*
First Name
Middle Name
Last Name
What school does Child 2 attend?
*
Please Select
Not in School
Mesabi East Elementary
Mesabi East High School
School Readiness
Early Childhood
Grade Level of Child 2
*
Please Select
Not in School
Pre-K
K
1
2
3
4
5
6
7
8
9
10
11
12
Date of Birth for Child 2
*
/
Month
/
Day
Year
Date
Is Child 2 a foster child?
*
Yes
No
Child 3
*
First Name
Middle Name
Last Name
What school does Child 3 attend?
*
Please Select
Not in School
Mesabi East Elementary
Mesabi East High School
School Readiness
Early Childhood
Grade Level of Child 3
*
Please Select
Not in School
Pre-K
K
1
2
3
4
5
6
7
8
9
10
11
12
Date of Birth for Child 3
*
/
Month
/
Day
Year
Date
Is Child 3 a foster child?
*
Yes
No
Child 4
*
First Name
Middle Name
Last Name
What school does Child 4 attend?
*
Please Select
Not in School
Mesabi East Elementary
Mesabi East High School
School Readiness
Early Childhood
Grade Level of Child 4
*
Please Select
Not in School
Pre-K
K
1
2
3
4
5
6
7
8
9
10
11
12
Date of Birth for Child 4
*
/
Month
/
Day
Year
Date
Is Child 4 a foster child?
*
Yes
No
Child 5
*
First Name
Middle Name
Last Name
What school does Child 5 attend?
*
Please Select
Not in School
Mesabi East Elementary
Mesabi East High School
School Readiness
Early Childhood
Grade Level of Child 5
*
Please Select
Not in School
Pre-K
K
1
2
3
4
5
6
7
8
9
10
11
12
Date of Birth for Child 5
*
/
Month
/
Day
Year
Date
Is Child 5 a foster child?
*
Yes
No
Child 6
*
First Name
Middle Name
Last Name
What school does Child 6 attend?
*
Please Select
Not in School
Mesabi East Elementary
Mesabi East High School
School Readiness
Early Childhood
Grade Level of Child 6
*
Please Select
Not in School
Pre-K
K
1
2
3
4
5
6
7
8
9
10
11
12
Date of Birth for Child 6
*
/
Month
/
Day
Year
Date
Is Child 6 a foster child?
*
Yes
No
Child 7
*
First Name
Middle Name
Last Name
What school does Child 7 attend?
*
Please Select
Not in School
Mesabi East Elementary
Mesabi East High School
School Readiness
Early Childhood
Grade Level of Child 7?
*
Please Select
Not in School
Pre-K
K
1
2
3
4
5
6
7
8
9
10
11
12
Date of Birth for Child 7
*
/
Month
/
Day
Year
Date
Is Child 7 a foster child?
*
Yes
No
Child 8
*
First Name
Middle Name
Last Name
What school does Child 8 attend?
*
Please Select
Not in School
Mesabi East Elementary
Mesabi East High School
School Readiness
Early Childhood
Grade Level of Child 8
*
Please Select
Not in School
Pre-K
K
1
2
3
4
5
6
7
8
9
10
11
12
Date of Birth for Child 8
*
/
Month
/
Day
Year
Date
Is Child 8 a foster child?
*
Yes
No
Child 9
*
First Name
Middle Name
Last Name
What school does Child 9 attend?
*
Please Select
Not in School
Mesabi East Elementary
Mesabi East High School
School Readiness
Early Childhood
Grade Level of Child 9
*
Please Select
Not in School
Pre-K
K
1
2
3
4
5
6
7
8
9
10
11
12
Date of Birth for Child 9
*
/
Month
/
Day
Year
Date
Is Child 9 a foster child?
*
Yes
No
Children's Ethnicity (optional)
Hispanic or Latino
Not Hispanic or Latino
Children's Race - check one or more (optional)
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
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Do Any Household Members (including you) currently participate in one or more of the following assistance programs: SNAP, MFIP or FDPIR? Medical assistance does not qualify.
*
Yes
No
Enter SNAP, MFIP or FDPIR Case Number (between 4-9 digits, do not report EBT card number)
*
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Last Four Digits of Social Security Number (SSN) of an Adult Household Member:
*
xxx-xx-____
Total Number of All Household Members (Children + Adults)
*
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
Child Income: Sometimes children in the household earn or receive income, such as from a part time job or SSI. Please include the TOTAL income received by all children in the household. Do not include income received by adults.
Total Income
$
Payment Frequency
Household Child Income
Weekly
Bi-Weekly
Twice Monthly
Monthly
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How many adult members are in your household? Please include children who are temporarily away at school or in college.
*
Please Select
1
2
3
4
Adult 1
*
First Name
Last Name
Adult 1 Income Report: Please report income for Adult 1 (before deductions) from working jobs, self-employment, farming, and other income such as social security, SSI, unemployment, public assistance, child support
Total Income
$
Payment Frequency
Gross Income from Working Jobs
Weekly
Bi-Weekly
Twice Monthly
Monthly
Gross Income from Self-Employment
or Farming
Weekly
Bi-Weekly
Twice Monthly
Monthly
Any Other Gross Income
Weekly
Bi-Weekly
Twice Monthly
Monthly
Adult 2
*
First Name
Last Name
Adult 2 Income Report: Please report income for Adult 2 (before deductions) from working jobs, self-employment, farming, and other income such as social security, SSI, unemployment, public assistance, child support
Total Income
$
Payment Frequency
Gross Income from Working Jobs
Weekly
Bi-Weekly
Twice Monthly
Monthly
Gross Income from Self-Employment
or Farming
Weekly
Bi-Weekly
Twice Monthly
Monthly
Any Other Gross Income
Weekly
Bi-Weekly
Twice Monthly
Monthly
Adult 3
*
First Name
Last Name
Adult 3 Income Report: Please report income for Adult 2 (before deductions) from working jobs, self-employment, farming, and other income such as social security, SSI, unemployment, public assistance, child support
Total Income
$
Payment Frequency
Gross Income from Working Jobs
Weekly
Bi-Weekly
Twice Monthly
Monthly
Gross Income from Self-Employment
or Farming
Weekly
Bi-Weekly
Twice Monthly
Monthly
Any Other Gross Income
Weekly
Bi-Weekly
Twice Monthly
Monthly
Adult 4
*
First Name
Last Name
Adult 4 Income Report: Please report income for Adult 2 (before deductions) from working jobs, self-employment, farming, and other income such as social security, SSI, unemployment, public assistance, child support
Total Income
$
Payment Frequency
Gross Income from Working Jobs
Weekly
Bi-Weekly
Twice Monthly
Monthly
Gross Income from Self-Employment
or Farming
Weekly
Bi-Weekly
Twice Monthly
Monthly
Any Other Gross Income
Weekly
Bi-Weekly
Twice Monthly
Monthly
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Signature
Clear
Name
First Name
Last Name
Submit
Should be Empty: