Enrollment Application for Benefits

Applicant Information

Please help us understand your situation by selecting from the list below.

Please select all that apply. Single parent 19 years old or younger Have children five (5) or younger Have a child with special needs Foster parent Grandparent/relative caring for young children Recently involved in domestic violence

Do you receive financial assistance from other organizations? Yes No

Household Information

Benefits will be based on everyone who currently lives in your home. Tell us about your current situation using the following boxes for each person living in your residence.

Applicant Details (Your Information)

Sex (M/F) Male Female

Are you a US citizen? Yes No

Additional Household Member #1

Sex (M/F) Male Female

US Citizen? Yes No

Additional Household Member #2

Sex (M/F) Male Female

US Citizen? Yes No

Additional Household Member #3

Sex (M/F) Male Female

US Citizen? Yes No

Additional Household Member #4

Sex (M/F) Male Female

US Citizen? Yes No

Additional Household Member #5

Sex (M/F) Male Female

US Citizen? Yes No

Additional Household Member #6

Sex (M/F) Male Female

US Citizen? Yes No

If you have additional household members, please enter the same information for any additional members below:

Household Expenses/Income

Please fill out the following sections so we can understand your situation and know how and if we can assist you.

Expenses

Is anyone in your household pregnant? Yes No

Do you or anyone in your household have any current medical expenses? Yes No

If you or anyone in your household has any unusual expenses not covered above, please explain:

Is there anyone in your household that does not have medical insurance? If yes, list names:

Household Income

Are there any extenuating circumstances that affect your current financial situation? Yes No

Monthly Totals

I understand the importance that all my information must be true and honest and that Opal’s Embrace is a nonprofit charitable organization that has limited funding. I understand Opal's Embrace will choose families based on their specific situation and on a first come, first serve basis. I understand that completed applications do not guarantee assistance.

Your electronic signature below also provides permission for Opal's Embrace to use images of you and/or your child for promotional purposes, which might include printed materials, social media, and on this website.

Please enter your electronic signature and date below: