HS & EHS Enrollment Application

Child Information

Applying For
Child Enrolled
Sex
Ethnicity (Hispanic)
Race
Applying For
Child Enrolled
Sex
Ethnicity (Hispanic)
Race
Applying For
Child Enrolled
Sex
Ethnicity (Hispanic)
Race
Parental Status
Relationship
Homeless
WIC
Do you receive Food Support?
Are you receiving public assistance?
Do you have medical/health insurance?
Would you like assistance in obtaining insurance?
Do you use IHS as your primary care? (IHS is not insurance)
Teen Parent (21 or under at birth of enrolling child)
Active in Military
US Military Veteran

Adult Family Members

Provides Financial Support
Insurance
Sex
Provides Financial Support
Insurance
Sex
Provides Financial Support
Insurance
Sex

Children

Insurance
Sex
Custody
Insurance
Sex
Custody
Was child referred to the program?
Child has disability or special need?
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