• Healthy Wallets, Healthy Lives Initiative Registration

    Register your family for the Healthy Wallets, Healthy Lives Initiative. Please complete all sections to confirm eligibility and interest.

  • Participant / Family Information

  • Format: (000) 000-0000.
  • Do you know your credit score

  • Eligibility Confirmation

  • Do you reside in Riviera Beach?*
  • Is your household low-to-moderate income?*

  • Program Component Interest

  • Which program components are you interested in?

  • Scheduling & Availability

  • Consent & Acknowledgments

  • Do you agree to attend sessions as required?*
  • Do you give permission for your child(ren) to participate in program activities?*

  • I consent to participate in all of the components of the program, and I understand that my signature is required to confirm this consent.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • How did you hear about this program?*

  • After submitting this application, please email the following supporting documents to dominionbiz@yahoo.com:

    1. Copy of a government-issued photo ID
    2. Current utility bill showing your home address
    3. Birth certificates for all children in the household
    4. Direct Certification Letter or other official documentation from the School District of Palm Beach County confirming eligibility for free or reduced-price school meals

    5. if applicable Pay stubs covering the most recent 30 days

     

    Please include the applicant’s full name in the subject line of the email.

     

  • Should be Empty: