HS/EHS Application Form
Child Information
Child Information
Name
Date of Birth
Gender
Male
Female
Other
Prefer not to say
Address
Child lives with:
Both Parents
Mom
Dad
Other guardians
Foster care
Is there custody paperwork?
Yes
No
n/A
Social Security Number (last 4 digits)
Primary Language
Health Insurance Provider
Race
American Indian or Alaskan Native
Asian
Black
Native Hawaiian or other Pacific Islander
Haitian
White
Multiracial
Ethnicity
Hispanic or Latino origin
Non-Hispanic or Latino origin
Is the family/child currently experiencing homelessness?
Yes
No
Add child
Parent/Guardian #1
Parent #1
Name
Date of Birth
Relationship to child
Gender
Male
Female
Other
Prefer not to say
Address
Phone
Format: (123) 456-7890
Health Insurance Provider
What is the best way to contact you?
Call
Text
Email
Home visit
Social Security Number (last 4 digits)
Primary Language
Race
American Indian or Alaskan Native
Asian
Black
Native Hawaiian or other Pacific Islander
Haitian
White
Multiracial
Ethnicity
Hispanic or Latino origin
Non-Hispanic or Latino origin
Email
Employment Status
Full time
Part time
Student
Unemployed
Education level (highest completed)
Kindergarten to 8th grade
9-12th grade
High school diploma / GED
No diploma
Some college / no degree
College graduate
Add parent
Add adult
Income/Earnings
Approximate family gross income
Submit