Child Dependent Information

Instructions for Client: Please fill out the information for each dependent in your household that is under 18 years of age. To ensure proper processing, all information provided is necessary. One form per dependent.

    *Gender:(CHOOSE ONE)

    *Is the dependent enrolled in school? (CHOOSE ONE)

    *Reason why dependent is not enrolled: (CHOOSE ALL THAT APPLY)
    • Lack of physical exam or missing medical record

    • Lack of immunization(s) or record(s)

    • Lack of proof of legal guardianship

    • Lack of transportation

    • Other

    *If the dependent is enrolled in school, please select the type of school: (CHOOSE ONE)

    **Student Body: (CHOOSE ONE)
    • Nursery/Pre-School

    • Kindergarten

    • Elementary School

    • Middle School

    • Approved Junior High School

    • Adult Education

    *School County: (CHOOSE ONE)

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