Student's Name *

First Name

Last Name

Parent/Guardian's Name *

First Name

Last Name

Phone *

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Does your household receive benefits from the Supplemental Nutrition Assistance Program (SNAP), the Food Distribution Program on Indian Reservations (FDPIR) or Temporary Assistance for Needy Family (TANF/Colorado Works – Basic Cash Assistance or State Diversion)?

Yes, SNAP

Yes, FDPIR

Yes, TANF/Colorado Works

None of the above

Is the student a foster child that is under the legal responsibility of a foster care agency or court?

Yes

No

Does your student meet the definition of homeless, runaway or migrant?

Do the members of your household lack a permanent address? Are you staying together in a shelter, hotel, or other temporary housing arrangement? Does your family relocate on a seasonal basis? Are any children living with you who have chosen to leave their prior family or household?

Yes

No