Enrollment Application for Benefits

Applicant Information

Name

First Last

Address

Street Address Address Line 2 City and State Zip Code

Home Phone

Work Phone

Cell Phone

Email Address

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

Please explain items checked in detail:

Do you receive financial assistance from other organizations?

Yes

If you answered yes, which ones:

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)

First, Middle, and Last Name

Sex (M/F)

Male

Female

Date of Birth

Race

Are you a US citizen?

Yes

Additional Household Member #1

First, Middle, and Last Name

Sex (M/F)

Male

Female

Date of Birth

Race

US citizen?

Yes

Additional Household Member #2

First, Middle, and Last Name

Sex (M/F)

Male

Female

Date of Birth

Race

US citizen?

Yes

Additional Household Member #3

First, Middle, and Last Name

Sex (M/F)

Male

Female

Date of Birth

Race

US citizen?

Yes

Additional Household Member #4

First, Middle, and Last Name

Sex (M/F)

Male

Female

Date of Birth

Race

US citizen?

Yes

Additional Household Member #5

First, Middle, and Last Name

Sex (M/F)

Male

Female

Date of Birth

Race

US citizen?

Yes

Additional Household Member #6

First, Middle, and Last Name

Sex (M/F)

Male

Female

Date of Birth

Race

US citizen?

Yes

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

If yes, list name and due date:

Enter your current rent or mortgage amount:

Enter your current monthly utilities amount:

Enter your current car payment:

Enter your current grocery bill:

Do you or anyone in your household have any current medical expenses?

Yes

If yes, enter amount:

Medical insurance expenses:

Monthly medication expenses:

Childcare/educational fees:

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

Gross income expected from your employment each month:

How often are you paid at your current job?

Other income not related to your job, alimony, or child support:

Your household’s money available in cash, checking, and savings:

Amount of alimony or child support that you receive each month:

Are there any extenuating circumstances that affect your current financial situation?

Yes

If yes, please explain below:

Monthly Totals

Monthly income:

Subtract monthly expenses:

Total:

What is your plan to improve your current financial situation?

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:

Signature (Full Name):

Date

Enrollment Application for Benefits

Applicant Information

Household Information

Household Expenses/Income

Additional Info