Grant Request Form
Complete this screening questionnaire to see if you qualify for the Mixed Delivery grant program.
Full Name
*
First Name
Last Name
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Child's Name (as it appears on birth certificate)
*
First Name
Last Name
Child's Zip Code
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child's Birthdate
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child's Gender
*
Female
Male
Other
Child's Race
*
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Is Child Hispanic or Latino?
*
Yes
No
Is Child in foster care?
*
Yes
No
Non-English language spoken at home as the primary language?
*
Yes
No
Parent/Guardian #1 activity requirement
*
Employed - Parent 1 is employed
Training program - Parent 1 is in training program
Job Search - Parent 1 is looking for a job
Parent/Guardian #1 income (include salary, child support, rental income, etc.)
*
annual income
Parent/Guardian #2 activity requirement
*
Employed - Parent 2 is employed
Training program - Parent 2 is in training program
Job Search - Parent 2 is looking for a job
There is not a Parent #2 in the household
Parent/Guardian #2 income (include salary, child support, rental income, etc.)
annual income
Total Parental/Guardian Income
*
Household Size
*
Include every adult & child living in the household
Other Eligibility Criteria (check all that apply)
Child is experiencing homelessness
Child's parents or guardians did not complete high school
Child has identified disability or receives early intervention (
Child is an English Language Learner
Single Parent Household
A parent is on military deployment for 3+ months during this fiscal year
Family is below the ALICE household survival budget: www.unitedforalice.org/alice-income-status-tool
Family has immigrated within the past 5 years
A parent was incarcerated within the past 5 years
Abuse or trauma in the household within the past 5 years
Child is in Kinship care
Both parents are younger than 20 years old
Families who are receiving other forms of government assistance, including but not limited to WIC, SNAP, and TANF
What date and time are you available for New Student Orientation?
Any other specific date and time, if the above selection is not suitable.
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Submit
Should be Empty: