ARP Application
Child Information
Child Name
*
First Name
Last Name
Sex
*
Date of Birth
*
-
Month
-
Day
Year
Date
Child Lives With
*
Both Parents
Mother
Father
Other
Parent Information
Mother
Parent Name (Mother)
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Marital Status
Married
Divorced
Single
Highest level of education completed
Please Select
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
GED
HS Diploma
College
Parent Information
Father
Parent Name (Father)
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Marital Status
Married
Divorced
Single
Highest level of education completed
Please Select
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
GED
HS Diploma
College
General Information
Names and ages of siblings in the household: (Type NA if no other siblings)
*
Does your child qualify for the free lunch program? (must have completed application for State At Risk funding or Child Nutrition Benefits)
*
YES
NO
Are you currently working with DCF?
*
YES
NO
Do you have an assigned case worker? (Reason for referral must be documented and signed by the DCF agent)
YES
NO
Upload reason for referral document if necessary
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Is the primary language spoken in the home a language other than English? (as documented by the State provided oral assessment or other standardized test) (attach documentation of home survey, assessment, and services)
*
YES
NO
Upload home survey documentation if necessary
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Is the child's family migrant? (A copy of the Certificate of Eligibility must be on file.
*
YES
NO
Certificate of Eligibility upload if necessary
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Is your child receiving any special services, i.e. speech therapy, learning disabilities, mentally handicapped, other (Do they have an IEP Individual Education Plan)?
*
YES
NO
Is the child developmentally or academically delayed based on assessments? (Assessments must be in the child's file)
*
YES
NO
Assessment upload if necessary
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Were either parent under the age of 20 years when the child was born? (verify by including birthdate above)
*
YES
NO
Parent/Guardian Signature
*
Submit
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