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Do You Qualify?
Fill out and submit this form to see if you are eligible for free health and dental care with HANDS of Saint Lucie.
11
Questions
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1
Full Name
*
This field is required.
First and Last Name are required only
First Name
Last Name
Suffix (Leave blank if none)
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2
Phone Number
*
This field is required.
Please enter a valid phone number.
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3
Email Address
*
This field is required.
example@example.com
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4
Are you a resident of Saint Lucie County?
*
This field is required.
YES
NO
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5
Are you between the ages of 19 and 64?
*
This field is required.
YES
NO
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6
Household Size
*
This field is required.
Please Select
1
2
3
4
5
6
7
8
9
10
Please Select
Please Select
1
2
3
4
5
6
7
8
9
10
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7
Monthly Household Income
*
This field is required.
Please Select
$0 to $2,510
$2,431 to $3,407
$3,288 to $4,303
$4,144 to $5,200
$5,001 to $6,097
$5,858 to $6,993
$6,714 to $7,890
$7,571 to $8,787
$8,428 to $9,683
$9,284 to $10,580
Please Select
Please Select
$0 to $2,510
$2,431 to $3,407
$3,288 to $4,303
$4,144 to $5,200
$5,001 to $6,097
$5,858 to $6,993
$6,714 to $7,890
$7,571 to $8,787
$8,428 to $9,683
$9,284 to $10,580
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8
Monthly Income Number
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9
Household Income Number
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10
Do you have insurance?
*
This field is required.
YES
NO
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11
Do you have Medicaid/Medicare?
*
This field is required.
YES
NO
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12
Do you qualify for Veterans benefits?
*
This field is required.
YES
NO
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13
Do they qualify?
*
This field is required.
Qualifies
Does not qualify
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14
Newsletter
Yes, I consent to receiving email from HANDS of Saint Lucie County.
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