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2. Family Member Name *
3. Age *
4. Grade *
6. Date of Birth *
7. School *
9. Family Member Name
10. Age
11. Grade
13. Date of Birth
14. School
16. Family Member Name
17. Age
18. Grade
20. Date of Birth
21. School
23. Family Member Name
24. Age
25. Grade
27. Date of Birth
28. School
30. Do you currently receive assistance from any of the following sources? (Please check all that apply) *

    1. Reduced Lunches
    2. Free Lunches
    3. Aid to Families with Dependent Children (AFDC)
    4. Commodities or Food Stamps
    5. Rent Supplement or Other Special Aid
    6. Any Other County, State or Federal Assistance (Please List in Next Question Space)
31. Other County, State or Federal Assistance Listed Here
33. I hereby affirm that the facts provided in the above statement are true and accurate to the best of my knowledge. (Please Type Parent/Guardian Name) *
34. Date of Application *
    Date of Application

    Date of Application
36. Upload Letter from the School District and Any Other Supporting Documents Here *
38. Additonal Document
40. Additional Document
Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit