Children with Special Health Care Needs Pre-Screen Form

If you are interested in applying for assistance in the Children with Special Health Care Needs program, please fill out the form below.

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Child's First Name

Child's Last Name

Child's Date of Birth

Parent or Legal Guardian Full Name

Address

City/Town

State/Province

ZIP/Postal Code

Phone Number

Confirm Email Address

Preferred Method of Contact

Phone

Email Address

Estimated Family Income

Please describe your child's medical condition below and what assistance we may provide