#areuin? Card Application
We are proud to offer students full scholarships and/or reduced pricing for certain programs and activities offered in our region.
Which application will you be applying with?
*
Please Select
Free / Reduced Lunch
Medicaid
Validator
Student Information
Student Name
*
First Name
Last Name
Student Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School District
*
Please Select
SAU 16 (Exeter School District)
SAU 21 (Seabrook School District)
SAU 50 (Portsmouth Area School District)
SAU 52 (Portsmouth School District)
SAU 90 (Hampton School District)
We DO NOT ACCEPT applications from any school districts not listed in the drop down.
School Name
*
Current Grade
*
Birth Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Please Select
Male
Female
Non-Binary
Prefer to Self Describe
Prefer not to respond
Race / Ethnicity
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latin
Middle Eastern or North African
Native Hawaiian or Pacific Islander
White
Prefer to Self Describe
Prefer not to respond
Please specify
Parent / Guardian Information
Parent / Guardian Name
*
First Name
Last Name
Parent / Guardian Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent / Guardian Email
*
example@example.com
Parent / Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please attach a photo of your current Free & Reduced Lunch Letter.
*
Browse Files
Drag and drop files here
Choose a file
This must be on school letterhead and include your child’s name and the benefit that they are receiving for the current 26-27 school year.
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of
Please attach a photo of your child’s NH Easy Account showing your child’s name and the active dates for which they are currently receiving NH Medicaid.
*
Browse Files
Drag and drop files here
Choose a file
PLEASE NOTE THAT WE NO LONGER ACCEPT PHOTOS OF PHYSICAL NH MEDICAID CARDS WITHOUT CURRENT COVERAGE DATES.
Cancel
of
How did you hear about us?
*
Please Select
#areuin? Card Family
Doctor's Office
Program Partner
School
Social Services Organization
Other
Parent/Guardian Waiver Agreement
*
Validator Information
Validator Name
*
First Name
Last Name
Validator Organization
*
Validator Email
*
example@example.com
Validator Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Validator Attestation
*
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Submit
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