Enrolled Child's Name *

First Name

Last Name

Birthdate of Enrolled Child *

MM

DD

YYYY

Parent Name *

First Name

Last Name

Parent Name (if 2nd parent in the home)

First Name

Last Name

Employment Status *

Full-Time employment

Part-Time employment

Unemployed

Student

2nd Parent Employment Status (if applicable)?

Full- Time employment

Part-Time employment

Unemployed

Student

Do your qualify or utilize SNAP Benefits? *

Yes

No

I Don't Know

Do you qualify or utilize WIC Benefits? *

Yes

No

I Don't Know

I understand submission of income verification form does not guarantee acceptance into the program. I also understand that if I falsify information or fail to submit information required for eligibility that I will be suspended or terminated and will be required to reimburse the program. *

Yes

No