Pre-K Registration Form

Location:(Required)

School Year:(Required)

FOR PROVIDER USE ONLY

Provider Legal Name:

School/Site Name:

CHILD'S INFORMATION

Child’s Full Name:(Required)

First Middle Last Suffix

Social Security Number:(Required)

Date of Birth:(Required)

Child’s Gender:

Male

Female

Home Address:(Required)

Street Address Address Line 2 City State ZIP Code

Home Phone Number:(Required)

If the Student is transferring from another Pre-K, please provide the following:

Previous School Name:

Last Date in Attendance:

PARENT/LEGAL GUARDIAN INFORMATION

Parent/Legal Guardian #1

Full Name:(Required)

First Middle Initial Last

Home Address (if different from child):

Street Address Address Line 2 City State ZIP Code

Home Phone:(Required)

Cell Phone:(Required)

Email Address:(Required)

Place of Employment:(Required)

Work Phone:(Required)

Employer’s Address:(Required)

Street Address Address Line 2 City State ZIP Code

Parent/Legal Guardian #2

Full Name:(Required)

First Middle Initial Last

Home Address (if different from child):

Street Address Address Line 2 City State ZIP Code

Home Phone:(Required)

Cell Phone:(Required)

Email Address:(Required)

Place of Employment:(Required)

Work Phone:(Required)

Employer’s Address:(Required)

Street Address Address Line 2 City State ZIP Code

EMERGENCY CONTACTS & AUTHORIZED PICK UP RESPONSES

1ST CONTACT / PICK UP PERSON

Name:(Required)

First Last

Relationship:(Required)

Cell Phone:(Required)

Alternate Phone:(Required)

Email:(Required)

2ND CONTACT / PICK UP PERSON

Name:

First Last

Relationship:

Cell Phone:

Alternate Phone:

Email:

Signature (Parent/Guardian):(Required)

Date:(Required)

CHILD MAINTENANCE

Child's Living Arrangements:(Required)

Both Parents

Mother

Father

Other

Child's Legal Guardian:(Required)

Both Parents

Mother

Father

Other

This child may be released to the person(s) signing this agreement or to the following:

Name

Address

Relationship

Cell Phone

(please use the + button to add more fields for each person)

Child's Physician or Clinic's Name (child's primary health source):(Required)

Date of Last Full Health Screening:(Required)

Phone:(Required)

My child has the following special need(s):(Required)

The following special accommodation(s) may be required to most effectively meet my child's needs while at this center:(Required)

My child is currently on medication(s) prescribed for long-term continous use and/or has the following pre-existing allergies, illness, or health concerns:(Required)

GENERAL RELEASE

Signature (Parent/Guardian):(Required)

Date:(Required)

PHOTOGRAPH/VIDEOTAPE RELEASE

Pre-K Provider Name/Address:(Required)

Signature (Parent/Guardian):(Required)

Date:(Required)

PRE-K PROGRAM - ROSTER INFORMATION FORM

This form is to be completed after school starts, not at the time of registration.

Today's Date:(Required)

Child's Legal Full Name (Nombre legal completo del niño):(Required)

First (Primer) Middle (Segundo) Last (Apellido) Suffix (Sufijo)

Child's Social Security Number (Número de seguro social del niño):(Required)

Date of Birth(Fecha de nacimiento):(Required)

Gender(Sexo):(Required)

Male

Female

Date enrolled in Pre-K:(Required)

If different from birth certificate, name student is called:

1. Everyone must answer the following question. (Todos deben contestar la pregunta

Is your child's ethnicity Hispanic/Latino/Spanish Origin, regardless of race? (¿Es Ud. Hispano/Latino o de Origen Hispano, sin importar la raza?)(Required)

Yes (Si)

No (No)

3. EVERYONE must select ONE OR MORE of the following races regardless of how you answered question one. (TODOS deben seleccionar UNA O MAS de las siguientes razas sin importar cómo haya contestado la primera pregunta.)

Is your child:(Required)

a. White A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. (Blanco - Una persona que tiene origenes en los pueblos provenientes de Europa, el Medio Oriente, o Africa del Norte).

b. Asian A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. (Asiática - Una persona con origenes en los pueblos provenientes del Lojano Oriente, Suroeste de Asia, o el subcontinente Hindú incluyendo, a Cambodia, China, India, Japón, Corea, Malasia, Pakistán, Las Filipinas, Tailandia, y Vietnam.)

c. Native Hawallan or Other Pacific Islander - A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. (Nativo de Hawall u Otra Isla del Pacifico Una persona con origenes en los pueblos provenientes de Hawaii, Guam, Samoa, u otra Isla del Pacifico.)

d. Black or African American - A person having origins in any of the Black racial groups of Africa. (Negro o Afro Americano - Una persona con origenes en los pueblos provenientes de! Africa o en grupo racial Negro.)

e. American Indian or Alaskan Native - A person having origins in any of the original peoples of North and South America including Central America, who maintains a tribal affiliation or community attachment. (Indio Americano o Nativo de Alaska - Una persona con origenes en los pueblos provenientes de América Del Norte y del Sur, incluyendo América Central, que mantiene una afiliación tribal o comunitaria.)

What is your child's primary language? (¿Cuál es el idioma primario de su hijo(a)?)(Required)

English (Inglés)

A language other than English (Un idioma diferente al Inglés)

4. Was your child born as a: (El parto en que Ud. tuvo a su hijo(a) fue de:)(Required)

Single Birth (1) (Un sólo niño)

Twin (2) (De mellizos)

Triplet (3) (De trillizos)

Quadruplet (4) (De cuatrillizos)

Quintuplet (5) (De quintuples)

5. Does your child have an Individualized Education Plan (IEP)? (¿Tiene su hijo(a) un Plan de Educación Individualizada (IEP?))(Required)

Yes (Si)

No (No)

6. Does your child receive any of the following services? (¿Recibe su hijo(a) alguno de estos servicios?)(Required)

Childcare and Parent Services (CAPS) (child care subsidy program)

Food Stamps (Cupones de Alimentos)

SSI

Medicaid

Temporary Assistance for Needy Families (TANF)

7. Will the Pre-K center be providing transportation for your child? (Recibirá su hijo(a) transporte en el Centro donde va a asistir a Pre-K?)(Required)

Yes (Si)

No (No)

Parent/Guardian Signature:(Required)

Date:(Required)

PARENTAL AGREEMENTS WITH CHILD CARE FACILITY

The "A Kid's World Ent. Inc" agrees to provide child care for:(Required)

(Name of child)

On Monday-Friday, beginning at 8:15AM and ending at 2:45 PM from August to May.

My child will participate in the following meal plan (check applicable meals and snacks):(Required)

Breakfast

Morning Snack

Lunch

Afternoon Snack

Evening Snack

Dinner

Bedtime Snack

Signature of Parent/Guardian:(Required)

Date:(Required)

Facility Administrator / Authorized Person Signature:

Date:

TRANSPORTATION AGREEMENT

Child’s Name:(Required)

Date of Birth:(Required)

Signature (Parent/Guardian):(Required)

Date:(Required)

TRANSPORTATION AGREEMENT FOR SCHOOL AGE USE ONLY

If the child relocates to another school or the hours change, this form must be updated.

Name of School:

School Phone:

School Address:

Street Address Address Line 2 City State ZIP Code

• In the event the designated location is unable to receive children they will be returned to AKW

• It is vital that AKW be notified of any changes in the above scheduled transportation.

• AKW will assume the above schedule of transportation will be followed unless we receive different instructions from parents. Instructions should be received at AKW no later than 1hr prior to pick up time.

To Above Listed School at (am/pm):

From Above Listed School at (am/pm):

On the following days (Please Check All That Apply)

Monday

Tuesday

Wednesday

Thursday

Friday

PHOTO RELEASE FORM

Child's Name:(Required)

Date:(Required)

Parent/Guardian Name:(Required)

Parent/Guardian Signature:(Required)

SOCIAL MEDIA RELEASE

Child’s Name:(Required)

Parent’s Signature:(Required)

AUTHORIZATION TO DISPENSE EXTERNAL PREPARATIONS

Parental Authorization. Except for first aid, personnel shall not dispense personnel shall not dispense prescription or non-prescription medications to a child without specific written authorization from the child’s physician or parent. Such authorization will include, when applicable, date; full name of the child; name of the medication; prescription number, if any; dosage; the dates to be given; the time of day to be dispensed; and signature of parent.

Check All That Apply(Required)

Baby Wipes

Band-Aids

Neosporin or similar ointment

Bactine or similar first aid spray

Sunscreen

Insect Repellent

Non-prescription ointment (such as A & D, Destin, Vaseline)

Baby Powder

Other

If Other, please specify:

Parent/Guardian Signature:(Required)

Date:(Required)

USDA FOOD PROGRAM

Dear Parents,
The USDA Food Program is a subsidized program that allows our center to provide high quality, large portioned meals to our children without any additional cost to our families.

In order for our center to qualify for this program we must prove that at least 25% of our families meet the “Free or Reduced” income standards. To do this we must maintain income verification forms on all families that attend our center. Even if you do not feel like your income would help us “qualify”, we still must maintain a verification form for your family. We must update our forms every August.

Please feel sure that this information is maintained separate from children’s records and only the management team had access to this information. This information is not used for any other purpose.

In addition, please complete all areas of this form! If your form is not filled out and signed, we have to count your family as a paid family regardless of your income!

Thank you for your help and understand. Please feel confident in knowing that our center’s participation in the USDA Food Program allows A Kid’s World to serve high quality meals to our children.

Sincerely,
Shannon Smith
Director/Owner
A Kid’s World
770-786-1587

Building For The Future

Meals
This day care facility participates in the Child and Adult Care Food Program (CACFP), a Federal program that provides healthy meals and snacks to enrolled participants receiving care.

Providers receive monetary reimbursement for serving nutritious meals that meet USDA requirements. The program plays a vital role in improving the quality of day care and making it more affordable for low-income families.

CACFP homes and centers follow meal requirements established by USDA.

Breakfast	Lunch or Supper	Snacks (Two of the five groups)
Milk Fruit or Vegetable Grains	Milk Meat or meat alternate Grains Fruit Vegetable	Milk Meat or meat alternate Grains Fruit Vegetable

Participating Facilities
Many different homes and centers operate the CACFP and share the common goal of bringing nutritious meals and snacks to participants. Participating facilities include:
• Child Care Centers: Licensed or approved public or private nonprofit child care centers, Head Start programs, and for-profit centers.
• Adult Care Centers: Licensed or approved public or private non-profit and some for-profit centers.
• Family Day Care Homes: Licensed or approved private child care homes.
• Afterschool Care Programs: Centers in low-income areas provide free snacks to school-age children and youth.
• Emergency/Homeless Shelters: Shelters that provide residential and food services to homeless children.
Shelters are the only residential programs that may participate.

Eligibility
State agencies reimburse facilities that offer non-residential day care to the following:
• children age 12 and under;
• migrant children age 15 and younger;
• youths through age 18 in afterschool care programs in needy areas;
• chronically impaired disabled adults 18 years of age or older; or
• persons 60 years of age or older in a group setting outside their home.

Contact Information This center participates on the CACFP under the sponsoring organization listed below. The CACFP is administered in every state and in Georgia by the agency listed below. Contact one of the following for questions about the CACFP.

Sponsoring Organization/Center Name, Address and Contact #

Bright from the Start: Department of Early Care and Learning Nutrition Services (Suite 754) 2 Martin Luther King, Jr. Dr., SE Atlanta, GA 30334 404-656-5987 www.decal.ga.gov

This institution is an equal opportunity provider.

WIC - A Special Food and Nutrition Education Program for Women, Infants and Children

WHO IS ELIGIBLE? » A pregnant woman » A breastfeeding woman » A woman who has recently been pregnant » An infant or a child less than 5 years old	TO BE ELIGIBLE, YOU MUST ALSO: » Have a low or moderate income AND » Have a special need that can be helped by WIC foods and nutrition counseling
APPROVED WIC FOODS: Milk, cheese, eggs, cereals, peanut butter, fruit or vegetable juices, dry beans or peas, iron fortified formula	SERVICES PROVIDED: » Nutritious foods » Nutrition counseling » Breast feeding support » Health care referral

You do not have to be on public assistance to apply. Call your local health department for more information.

GEORGIA WIC PROGRAM
Georgia Department of Public Health
2 Peachtree Street NW, 10th Floor
Atlanta, GA 30303
Telephone: 1-800-228-9173
Website: http://dph.georgia.gov/WIC

INCOME ELIGIBILITY GUIDELINES
(Effective from July 1, 2021 to June 30, 2022)

Household Size	Reduced Meal Income Limits
	Annually	Monthly	Twice A Month	Every Two Weeks	Weekly
1 …..	23,828	1,986	993	917	459
2 …..	32,277	2,686	1,343	1,240	620
3 …..	40,626	3,386	1,693	1,563	782
4 …..	49,025	4,086	2,043	1,886	943
5 …..	57,424	4,786	2,393	2,209	1,105
6 …..	65,823	5,486	2,743	2,532	1,266
7 …..	74,222	6,186	3,093	2,855	1,428
8 …..	82,621	6,886	3,443	3,178	1,589
For each additional family member add	+ 8,399	+700	+ 350	+324	+162

A Kid's World Enterprises, Inc

A Kid's World Enterprises, Inc

Dear Parent/Guardian:
This letter is intended for parents or guardians of children enrolled in a child care center. A Kid's World offers healthy meals to all enrolled children as part of our participation in the U.S. Department of Agriculture's (USDA) Child and Adult Care Food Program (CACFP). The CACFP provides reimbursements for healthy meals and snacks served to children enrolled in child care. Please help us comply with the requirements of the CACFP by completing the attached Meal Benefit Income Eligibility Form. In addition, by filling out this form, we will be able to determine if your child(ren) qualifies for free or reduced price meals.
1. Do I need to fill out a Meal Benefit Form for each of my children in day care? You may complete and submit one CACFP Meal Benefit Income Eligibility Form for all children enrolled in child care in your household only if the children in child care are enrolled in the same center. We cannot approve a form that is not complete, so be sure to read the instructions carefully and fill out all required information. Return the completed form to: [(Name of Center, address, phone number].

2. Who can get free meals without providing income information? Children in households getting Supplemental Nutrition Assistance Program (SNAP) (formerly Food Stamps). Temporary Assistance for Needy Families (TANF), or Food Distribution Program on Indian Reservations (FDPIR) benefits can get free meals. Foster children and children enrolled in Head Start are also eligible for free meals. Children in households participating in WIC may be eligible for free meals.

3. Who can get reduced price meals? Your children can get low cost meals if your household income is within the reduced price limits on the Federal Income Chart, shown on this application. Children in households participating in WIC may be eligible for reduced price meals.

4. May I fill out a form if someone in my household is not a U.S. citizen? Yes. You or your children do not have to be U.S. citizens to qualify for meal benefits offered at the child care center.

5. Who should I include as members of my household? You must include everyone in your household (such as grandparents, other relatives, or friends who live with you) who shares income and expenses. You must include yourself and all children who live with you. You also may include foster children who live with you.

6. How do I report income information and changes in employment status? The income you report must be the total gross income listed by source for each household member received last month. If last month's income does not accurately reflect your circumstances, you may provide a projection of your monthly income. If no significant change has occurred, you may use last month's income as a basis to make this projection. If your household's income is equal to or less than the amounts indicated for your household's size on the attached Income Chart, the center will receive a higher level of reimbursement. Once properly approved for free or reduced price benefits, whether through income or by providing a current SNAP, TANF, FDPIR case number, you will remain eligible for those benefits for 12 months. You should notify us, however, if you or someone in your household becomes unemployed and the loss of income causes your household income to be within the eligibility standards.

7. What if my income is not always the same? List the amount that you normally get. For example, if you normally get $1000 each month, but you missed some work last month and only got $900, put down that you get $1000 per month. If you normally get overtime, include it, but not if you only get it sometimes.

8. What if I have foster children? Foster children that are under the legal responsibility of a foster care agency or court are eligible for free meals. Any foster child in the household is eligible for free meals regardless of income. Households may include foster children on the Meal Benefit Form, but are not required to include payments received for the foster child as income. Households wishing to apply for such benefits for foster children should contact [name, address, phone number].

9. We are in the military, do we include our housing and supplemental allowances as income? If your housing is part of the Military Housing Privatization Initiative and you receive the Family Subsistence Supplemental Allowance, do not include these allowances as income. Also, in regard to deployed service members, only that portion of a deployed service member's income made available by them or on their behalf to the household will be counted as income to the household. Combat Pay, including Deployment Extension Incentive Pay (DEIP) is also excluded and will not be counted as income to the household. All other allowances must be included in your gross income.

10. (Pricing program only) Will the information I give be verified? Maybe. We may ask you to send written proof to verify the information you submitted on the form. What if I disagree with the decision about the information I complete on this form? You should talk to you're a Kid's World

In the operation of child feeding programs, no person will be discriminated against because of race, color, national origin, sex, age or disability.

If you have other questions or need help, call 770-786-1587.

Sincerely,
Shannon Smith

CACFP Meal Benefit Income Eligibility Statement

PART I: Child(ren) or Adult enrolled to receive day care

1. Name:

First Middle Initial Last

SNAP, TANF, or FDPIR case number, or Client ID number for children only. All the above, or SSI or Medicaid case number for Adults. Note: Do not use EBT numbers. Write case number and proceed to Part Ill.

Children in Head Start, foster care and children who meet the definition of migrant, runaway, or homeu0002less are eligible for free meals:

Head Start

Foster Child

Migrant

Runaway

Homeless

(Check All That Apply)

2. Name:

First Middle Initial Last

Children in Head Start, foster care and children who meet the definition of migrant, runaway, or homeu0002less are eligible for free meals:

Head Start

Foster Child

Migrant

Runaway

Homeless

(Check All That Apply)

3. Name:

First Middle Initial Last

Children in Head Start, foster care and children who meet the definition of migrant, runaway, or homeu0002less are eligible for free meals:

Head Start

Foster Child

Migrant

Runaway

Homeless

(Check All That Apply)

4. Name:

First Middle Initial Last

Children in Head Start, foster care and children who meet the definition of migrant, runaway, or homeu0002less are eligible for free meals:

Head Start

Foster Child

Migrant

Runaway

Homeless

(Check All That Apply)

5. Name:

First Middle Initial Last

Children in Head Start, foster care and children who meet the definition of migrant, runaway, or homeu0002less are eligible for free meals:

Head Start

Foster Child

Migrant

Runaway

Homeless

(Check All That Apply)

PART II: Report income for ALL Household Members (Skip this step if participant is categorically eligible as documented in Part 1.) Are you unsure what income to include here? Flip the page and review the charts titled “Sources of Income” for more information.

A. Child lncome1 - Sometimes children in the household earn or receive income. Please indicate the TOTAL income received by child household members listed in PART I here

Child Income:

How Often?

B. Other Household Members1 - List all household members even if they do not receive income. Also, list the adult participant if he/she did not meet eligibility in Part I. For each Household Member listed, if they do receive income, report total gross income (before taxes) for each source in whole dollars (no cents) only. If they do not receive income from any source, write ‘O’. If you enter “O” or leave any field blank you are certifying (promising) there is no income to report

1. Name of Other Household Member:

Earnings from work before deductions:

How Often?

Welfare, child support, alimony:

How Often?

Social Security, pensions, retirement:

How Often?

All other incomes:

How Often?

2. Name of Other Household Member:

Earnings from work before deductions:

How Often?

Welfare, child support, alimony:

How Often?

Social Security, pensions, retirement:

How Often?

All other incomes:

How Often?

3. Name of Other Household Member:

Earnings from work before deductions:

How Often?

Welfare, child support, alimony:

How Often?

Social Security, pensions, retirement:

How Often?

All other incomes:

How Often?

4. Name of Other Household Member:

Earnings from work before deductions:

How Often?

Welfare, child support, alimony:

How Often?

Social Security, pensions, retirement:

How Often?

All other incomes:

How Often?

5. Name of Other Household Member:

Earnings from work before deductions:

How Often?

Welfare, child support, alimony:

How Often?

Social Security, pensions, retirement:

How Often?

All other incomes:

How Often?

C. Total Household Members (Adults and Children) listed in Part I and Part II

Total Household Members:

Social Security Number. If income is listed or completed in Part II, the adult completing the form must also list the last four digits of his or her Social Security Number or check the “I don’t have a Social Security Number” box below. (See Privacy Act Statement on next page). Failure to complete this section, if income is listed, will result in the denial of free or reduced eligibility

Last four Digits of Social Security Number XXX-XX:

PART III: Enrollment Information Children Only

My child is normally in attendance at the facility between the hours of (am/pm):

To (am/pm):

Check the days your child will normally attend the center:

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Check the meals your child will normally receive while in care:

Breakfast

AM Snack

Lunch

PM Snack

Supper

Evening Snack

PART IV: Signature

*This application Is a revision of USDA’s newly released meal benefit prototype and meets all legal requirements and reflect design best practices identified by USDA through focus testing and other research

Signature: X

Print Name:

Date:

Phone:

Address:

Street Address Address Line 2 City State ZIP Code

PART V: Participant’s Ethnic and Racial Identities (optional)

Select one ethnic identity:

Hispanic/ Latino

Not Hispanic/ Latino

Check one or more racial identities:

Asian

Black or African American

Hawaiian or other Pacific Islander

White

Indian or Alaska Native

Official Use Only Section for Provider: Annual Income Conversion: Weekly x 52, Every 2 weeks x 26, Twice a month x 24, Monthly x 12

Total income: Per: ☐ Week ☐ Every 2 Weeks ☐ Twice a month ☐ Monthly ☐ Yearly ☐ Household Size:

Categorical Eligibility: check ( ☐ ) if applicable Eligibility: check ONE ( ☐): Free ☐ Reduced ☐ Paid

Day Care Homes Only: check ( ☐) ONE ☐ Tier I ☐ Tier II

When more than one person is performing CACFP duties, there must be at least two signatures on this form: one signature from the Determining Official (the official who determined initial income classification) and one signature from the Confirming Official (the official who verified the form’s accuracy).

Determining Official’s Signature: Date

Confirming Official’s Signature: Date

Follow Up Official’s Signature: Date

CAPTCHA

Comments

This field is for validation purposes and should be left unchanged.

Pre-K Registration Form

EMERGENCY CONTACTS & AUTHORIZED PICK UP RESPONSES

CHILD MAINTENANCE

GENERAL RELEASE

PHOTOGRAPH/VIDEOTAPE RELEASE

PRE-K PROGRAM - ROSTER INFORMATION FORM

PARENTAL AGREEMENTS WITH CHILD CARE FACILITY

TRANSPORTATION AGREEMENT

TRANSPORTATION AGREEMENT FOR SCHOOL AGE USE ONLY

PHOTO RELEASE FORM

SOCIAL MEDIA RELEASE

AUTHORIZATION TO DISPENSE EXTERNAL PREPARATIONS

USDA FOOD PROGRAM

Building For The Future

WIC - A Special Food and Nutrition Education Program for Women, Infants and Children

A Kid's World Enterprises, Inc

CACFP Meal Benefit Income Eligibility Statement

PART I: Child(ren) or Adult enrolled to receive day care

PART II: Report income for ALL Household Members (Skip this step if participant is categorically eligible as documented in Part 1.) Are you unsure what income to include here? Flip the page and review the charts titled “Sources of Income” for more information.

PART III: Enrollment Information Children Only

PART IV: Signature

PART V: Participant’s Ethnic and Racial Identities (optional)

Loganville

Covington

Have Questions?

Pre-K Registration Form

EMERGENCY CONTACTS & AUTHORIZED PICK UP RESPONSES

CHILD MAINTENANCE

GENERAL RELEASE

PHOTOGRAPH/VIDEOTAPE RELEASE

PRE-K PROGRAM - ROSTER INFORMATION FORM

PARENTAL AGREEMENTS WITH CHILD CARE FACILITY

TRANSPORTATION AGREEMENT

TRANSPORTATION AGREEMENT FOR SCHOOL AGE USE ONLY

PHOTO RELEASE FORM

SOCIAL MEDIA RELEASE

AUTHORIZATION TO DISPENSE EXTERNAL PREPARATIONS

USDA FOOD PROGRAM

Building For The Future

WIC - A Special Food and Nutrition Education Program for Women, Infants and Children

A Kid's World Enterprises, Inc

CACFP Meal Benefit Income Eligibility Statement

PART I: Child(ren) or Adult enrolled to receive day care

PART II: Report income for ALL Household Members (Skip this step if participant is categorically eligible as documented in Part 1.) Are you unsure what income to include here? Flip the page and review the charts titled “Sources of Income” for more information.

PART III: Enrollment Information Children Only

PART IV: Signature

PART V: Participant’s Ethnic and Racial Identities (optional)

Loganville

Covington

Have Questions?

BRANFORD – 203-488-5437

CHESHIRE – 203-271-1147

WALLINGFORD – 203-269-5437