Highest of Education Completed: Date Completed: ___ ___ ___ Race*: only one) Ethnicity: (Please specify below)  American Indian/Alaskan Native Hispanic/Latino Person’s Ethnicity is Latino  Asian Native Hawaiian or Other Pacific Islander or Hispanic  Black or African American White Bi-racial/Multi-Racial Specify How well does this person Other Specify English?  Unknown Very well Well  Not well Not at all       Occupational Status: Full Time Part Time Retired Unemployed Home Maker Disabled Employer: Address: _ _ _ _ Telephone: Work Hours: _ _ _    Education Status: School Full Time School Part Time School Hours: _ _ School: Address: _ _ Telephone: _ _ _ _ _ #2 PARENT/GUARDIAN First Name: MI Last Name: DOB:* Gender: Male Female □ □ Email address:   Can you receive texts? Yes No Marital Status: Person is Head of Household:      Married Single Separated Divorce Partner Yes No Relationship to Child:     Biological parent Grandparent Parent’s significant other Foster Parent Legal guardian  Step Parent Other     Is person currently pregnant? Yes Person in same household as child? Yes No No If yes, when is due date? Race*: (Check only one) Ethnicity: (Please specify below)  American Indian/Alaskan Native Hispanic/Latino  Native Hawaiian or Other Pacific Islander Person’s Ethnicity is Latino  or Hispanic or African American White Bi-racial/Multi-Racial Specify How well does this person Other Specify speak English?  Very well Well Unknown  Not well Not at all Highest Level of Education Completed: Date Completed:___ ___ ___ __ ___
Highest of Education Completed: Date Completed: ___ ___ ___ Race*: only one) American Indian/Alaskan Native  Hispanic/Latino Asian  Native Hawaiian or Other Pacific Islander Black or African American  White Bi-racial/Multi-Racial Specify Other Specify Unknown Ethnicity: (Please specify below) Person’s Ethnicity is Latino or Hispanic How well does this person English? Very well  Well Not well  Not at all Occupational Status:  Full Time  Part Time  Retired  Unemployed  Home Maker  Disabled Employer: Address: _ _ _ _ Telephone: Work Hours: _ _ _ Education Status:  School Full Time  School Part Time  School Hours: _ _ School: Address: _ _ Telephone: _ _ _ _ _ #2 PARENT/GUARDIAN First Name: MI Last Name: DOB:* Gender: □ Male □ Female Can you receive texts?  Yes  No Email address: Marital Status: Married  Single  Separated  Divorce  Partner Person is Head of Household: Yes  No Relationship to Child: Biological parent  Grandparent  Parent’s significant other  Foster Parent  Legal guardian Step Parent  Other Person in same household as child?  Yes  No Is person currently pregnant?  Yes  No If yes, when is due date? Race*: (Check only one) American Indian/Alaskan Native  Hispanic/Latino  Native Hawaiian or Other Pacific Islander or African American  White Bi-racial/Multi-Racial Specify Other Specify Unknown Ethnicity: (Please specify below) Person’s Ethnicity is Latino or Hispanic How well does this person speak English? Very well  Well Not well  Not at all Highest Level of Education Completed: Date Completed:___ ___ ___ __ ___
2015-Application-Packet.docx