Healthy Wallets, Healthy Lives Initiative Application

Healthy Wallets, Healthy Lives Initiative Application

Please complete the application for Mayor Douglas Lawson's Healthy Wallets, Healthy Lives Initiative. Provide caregiver, household, child, health/dietary, and consent information. The form header image is set from the provided URL.
Caregiver & Household Information
Primary Caregiver Full Legal Name

First NameMiddle NameLast Name
Residential Address (Riviera Beach)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Total Number of Individuals in Household
Number of Dependent Children
Household Income Level
Current Safety-Net or Assistance Program Participation

Other
Participating Child Information
Child's Full Name

First NameMiddle NameLast Name
Child's Age
Child's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
School Name
Health & Dietary Considerations
Child's Full Name
Program Commitments
Caregiver Agreement and Commitment Acknowledgment

Other
Media and Data Release Consent

Other
Should be Empty: