Child's Name
Childs Age
|
Add date:
Drop date:
If drop, give reason:
|
Campus:
Room:
Dually enrolled classes:
AM
PM
FSW |
Childs date of birth:
Gender:
Female
Male
Race:
Black/African American
White
Hispanic
Asian
Bi-Racial
Native American
|
Annual Income:
Household Type
Single parent
Two parent
|
Eligibility:
Income Eligible
Income Eligible 130%
Above Guidelines
SSI
TANF
|
Childs medical insurance at time of enrollment:
Medicaid
CHIPS
Private
None
|
