Name of Parent *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Child's First and Last name *

First Name

Last Name

Date of birth

MM

DD

YYYY

Phone *

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###

####

Check all that apply *

I am on WIC/ Medicaid/ Medicare/ Food Stamps

I do not have insurance

My household income is less than 400 percent of the federal poverty level

I am/ My partner is a federal government employee or contractor former/ current that is unable to self pay