Apply Online Contact Information Your First & Last Name* Your Date of Birth* If you are applying for more than one child, please fill out a new application for each. Child's First & Last Name* Child's Date of Birth* If you do not have an email address leave this field blank. Email Phone* Street Address City State---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingPuerto Rico Zip Preferred Contact Language?EnglishSpanish Questions How many people (related by blood, marriage or adoption and supported by the income of the parent or guardian of the applying child) currently live in your home?* What is your family’s GROSS MONTHLY income? Proof of income required prior to enrollment. Please select any of the following statements if it applies to you or a member of your family. Please select all that apply. Use Control and Click to select more than one:* In Foster CareReceives Supplemental Security Income, TANF, TEA, Work Pays, Career Pathways, or Community Investments Initiative funds?Enrolling Child has a Documented DisabilityLiving in a ShelterAwaiting Foster PlacementLiving in a Car/VehicleLiving with a Friend/Relative due to Economic HardshipLack a fixed, regular and adequate Nighttime ResidenceNone of these Apply *Required Fields