Service Members, Veterans, and Families (SMVF) Program Application

Service Members, Veterans, and Families (SMVF) Program Application

Complete this eligibility and enrollment application for the Service Members, Veterans, and Families (SMVF) program.
Primary Caregiver / Applicant Information
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Best Way to Reach You
Best Time to Reach You

Hour Minutes

AM/PM Option
Email Address
example@example.com
Preferred Language
Street Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
County of Residence
Total Household Size
How did you hear about the program?
Military Connection
“Military-Connected” means a current or former direct relationship with the military (active-duty, veteran, reservist, or National Guard).
Who in your family is Military-Connected?
Branch of service
Name of the Military-Connected family member (if not the applicant)
Relationship to the applicant
Family & Child/Youth Information
Family status
Index child/youth date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Index child/youth full name

First NameMiddle NameLast Name
Sex
Relationship to this child or pregnancy
Known developmental, health, or behavioral concerns
Other Children/Youth in the Home
Other children/youth in the home
Eligibility Screening
Are you entering this program voluntarily, of your own choice?
Is your family currently involved in an open Child Protective Investigation (CPI) or Child Protective Services (CPS) case?
Priority Characteristics
Priority characteristics
Help text
Consent & Signature
Consent Statement
Social Security Number (optional)
Agreement and Consent
E-Signature / Legal Name

First NameMiddle NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Service Members, Veterans, and Families (SMVF) Program Application

Primary Caregiver / Applicant Information

Military Connection

Family & Child/Youth Information

Other Children/Youth in the Home

Eligibility Screening

Priority Characteristics

Consent & Signature