Apply for Support Fields marked with an asterix (*) are required. If support is needed for more than one student within the same home or family, please submit a separate application for each student in need.Please provide as many details as possible for each form entry. This will help ensure we can meet the specific needs of each family or student in need within our program. Parent, Foster Parent or Guardian (if possible) First Name Middle Name Last Name First Name Middle Name Last Name Phone Number – Area Code Phone Number Student Name * First Name Middle Name Last Name Birth Date * January February March April May June July August September October November December Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Year Gender * Male Female N/A Height * Weight * Ethnicity Phone Number – Area Code Phone Number Address (If Applicable) Street Address Street Address Line 2 City State / Province Postal / Zip Code Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Nagorno-Karabakh Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Turkish Republic of Northern Cyprus Northern Mariana Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Republic of the Congo Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia South Sudan Spain Sri Lanka Sudan Suriname Svalbard eSwatini Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Transnistria Pridnestrovie Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands Isle of Man US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country Does the student take part in the Reduced or Free meal programs that are offered for the school district? * Yes No If so, does the student participate in the Reduced or Free Breakfast, Lunch, or both? Select all that apply. Reduced Breakfast Free Breakfast Reduced Lunch Free Lunch If not, what is the reason? (distance, schedule, paperwork issues, life or living situation, etc.) Student E-mail Current School What are the student’s interests & activities? (Academics, Sports, Music, Art, Band, Outdoors, Church, etc. List all that apply.) Does the student have a safe place to live, sleep, bathe & study everyday? If so, please provide as much detail as possible. Does the student have access to the following? 24/7 Electricity Air Conditioning Fans Heaters Personal Tablet or Computer School Tablet or Computer Running Hot & Cold Water Refrigerator Freezer Internet Access Moderate Internet Access No Internet Access Does the student have enough nutritious food for each meal, Daily & Weekly (Including Weekends)? If so, what does a typical breakfast, lunch & dinner consist of on Weekdays & Weekends? Does the student have any food allergies or special dietary needs? (Nut Allergies, Dairy, Diabetes, etc.) Please explain in detail. Is the student in need of clothing, shoes, bed, bedding, blankets, electric fan and/or heater, cooking utensils, etc? Additional Comments Apply Now Clear Fields Should be Empty:
