HS/EHS Application Form

Start with the primary child information below. Add additional children if needed.

Name Date of Birth Sex What type of programming are you interested in?

Choose the program that best matches your current need.

Address Child lives with Is there custody paperwork?

Social Security Number (last 4 digits)

Only enter the last 4 digits.

Primary Language Health Insurance Provider Race Ethnicity Is the family/child currently experiencing homelessness?

Enter the primary parent or caregiver information below. Add additional parents/caregivers if needed.

Name Date of Birth Relationship to child Sex Address Phone

Enter a 10-digit phone number, such as 123-456-7890.

Health Insurance Provider What is the best way to contact you?

Social Security Number (last 4 digits)

Only enter the last 4 digits.

Primary Language Race Ethnicity Email

We will use this email for confirmation and follow-up.

Employment Status Education level (highest completed)

Provide the best estimate you have. This information helps determine eligibility and follow-up needs.

Approximate family gross income

A monthly or yearly estimate is fine.

Do you receive SNAP? Do you receive Public Assistance? Do you receive Housing Assistance?

After submission, you will be taken to a confirmation page with your reference ID.