Application For Admission

1. Applicant Information (Head of Household)
2. Household Composition
List Persons in household 18 and over (Head of Househould Required)
List Persons in household under 18
Emergency Contact
3. Total Household Income

List all money earned or received by everyone living in the household. This includes, but is not limited to, gross wages, self employment, child support, Social Security, SSI, Worker's Compensation, Unemployment benefits, retirement benefits, TANF, Veteran's benefits, alimony, babysitting, rental property income. Income from banks such as interest on saving bonds, checking accounts, and CDs. Also, include any regular contributions to the household from any person outside the household.

4. Assets

Do any household members have or receive income from assets? (Check all that apply)

5. Childcare and Medical Information

If the Head of Household or Spouse are age 62 or older OR disabled regardless of age, list all medical expenses anticipated for the next 12 months that will not be reimbursed by insurance or other outside source. (This includes but is not limited to: prescriptions, physicians bills, hospital bills, insurance premiums, and over-the-counter medications) Back-up info required.

6. General Information
7. Program Integrity Information (these questions apply to all household members)
8. Consent