2
Child 3: M / F
Name (first) (last) DOB Gender
School currently attending Grade
Interests
Child 4: M / F
Name (first) (last) DOB Gender
School currently attending Grade
Interests
Child 5: M / F
Name (first) (last) DOB Gender
School currently attending Grade
Interests
Household Annual Income: $
Do you receive any government assistance? Yes No
Current Government assistance program(s):
Additional Information: (Why you need assistance from this program: anything important for us to know when
considering your application)
Applicant Signature: Date:
***Last day to turn in applications is November 30
th
, 2020. If the application is not complete or the contact
information is not valid your application will not be processed***
***Please note you are not considered to be registered for the program until contacted by a representative of this
organization and given a program receipt***
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signature
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