Household Information
The following form is a membership application for the DAYS Long Beach 2020 summer program. We are collecting one application per household for up to five children. All information is confidential and will solely be used for programming purposes. If you would like to enroll more than five children, please submit a second application. Questions? Email info@dayslb.org
Email address *
1. Primary Contact First Name *
2. Primary Contact Last Name *
3. Household Street Address *
4. Household Apartment or Unit Number (leave blank if none)
5. Household City *
6. Zip Code *
Confidential Information
The following information is necessary for our records and the funding our program receives. The answers you provide are confidential.
7. Do children in this household qualify for free or reduced lunch school program?
Clear selection
8. Combined Annual Household Income (please check one only)
Clear selection
9. Health Insurance *
If you have private insurance or are insured through your job, enter Other and include insurance name, policy number, and phone number
10. Family Physician name, address, and phone number *
Next
Never submit passwords through Google Forms.
This form was created inside of DAYS Long Beach. Report Abuse