Section 1. Participant Background (continued) The participant lives in housing that is: Family Owned (Check all that apply) housing OR The participant is: Is or has the participant ever been in foster care: Yes No Has the participant been enrolled in programs operated by the Administration for Yes information Children’s Services (ACS)? Is the participant or any member of the household (0-64 years old) covered by Yes Medicaid, Child Health Plus, Health Plus, or private health insurance? If you answered no to the previous question, would you like to be contacted by Yes household someone for assistance with health insurance? Number of individuals in your household: and * Is the participant or any member of your household receiving public assistance? Yes family * Is the participant or any member of your household receiving food stamps? Yes No other * Gross Yearly Household Income: $ The participant lives in a household Self, Single, Single Parent Two Parents no children Single Parent Two Adults, no children that is headed by: * Sources of household income: Employment TANF Social Security Unemployment Insurance Pension SSI General Assistance PARTICIPANT SAFETYPlease place parent info in the emergency contact boxes if applicable. EMERGENCY CONTACTS. If there is an emergency, please contact the following individuals:
Section 1. Participant Background (continued) other family and household information The participant lives in housing that is: (Check all that apply) Owned housing OR The participant is: Is or has the participant ever been in foster care: Yes Has the participant been enrolled in programs operated by the Administration for Children’s Services (ACS)? Yes Is the participant or any member of the household (0-64 years old) covered by Medicaid, Child Health Plus, Family Health Plus, or private health insurance? Yes If you answered no to the previous question, would you like to be contacted by someone for assistance with health insurance? Yes Number of individuals in your household: * Is the participant or any member of your household receiving public assistance? Yes No * Is the participant or any member of your household receiving food stamps? Yes No * Gross Yearly Household Income: $ The participant lives in a household that is headed by: Self, Single, no children Single Parent Single Parent Two Parents Two Adults, no children * Sources of household income: Employment Pension TANF SSI Social Security General Assistance Unemployment Insurance PARTICIPANT SAFETYPlease place parent info in the emergency contact boxes if applicable. EMERGENCY CONTACTS. If there is an emergency, please contact the following individuals:
FY18-Manhattan-Charter-School-2_Program-Application.docx