Language
English (US)
Portuguese (Brazil)
Spanish (Latin America)
Family ID Registration Form
2026
What is your preferred language for communication?
*
Please Select
English
Spanish
Portuguese
Ethnicity
Please Select
African American
Asian
Hispanic/Latino
Native American
Two or more races
Caucasian
Parent Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
What is your annual family income?
*
Please Select
$.00 - $10.000
$10,001 - $20,000
$20,001-$30,000
$30,001 - $40,000
$40,001 - $50,000
$50,001 - $60,000
$60,001 - $70,000
$70,000 - $75,000
Over $75,000
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Parent #2 information:
First Name
Last Name
Parent #2 Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Parent #2 Email
example@example.com
Which Jericho programs have you been involved with in the past year? Check all that apply.
*
Food Pantry
After School Program
Summer Learning Program
Bags of Love (Thanksgiving)
Angel Tree (Christmas)
None
Please complete the following information for each child.
Rows
Child's Name (First):
Child's Name (Last)
Date of Birth (MM/DD/YEAR)
Grade
Child #1
K
1
2
3
4
5
6
7
8
9
10
11
12
Child #2
K
1
2
3
4
5
6
7
8
9
10
11
12
Child #3
K
1
2
3
4
5
6
7
8
9
10
11
12
Child #4
K
1
2
3
4
5
6
7
8
9
10
11
12
Which State programs are you currently enrolled with? Check all that apply.
*
Food Stamps
Energy Assistance
WIC
Husky Part A, Part B
State Administered General Assistance (SAGA)
Temporary Assistance to Needy Families (TANF)
Aid to the Blind or Disabled
Social Security Supplemental (SSI)
Section 8 Rental Assistance Program
None
If you have checked any of the above services/programs, please attach a copy/copies of ID card or proof of participation.
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Please upload a copy of at least one parent's ID AND each child's birth certificate here:
*
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