Growwth Inquiry Form

NOTE: In order to be enrolled in the GROWWTH Program, you have to be a parent with a child under the age of 18 in the home that you care for and are the guardian of.

Name*

Phone Number*

Format: (xxx) xxx-xxxx

Email Address

Address

(Mailing Address, City, State, Zip)

County*

To help us determine potential eligibility for GROWWTH, please answer the following:

Are you the parent or guardian of a child 18 years old or younger who shares primary residence with you?

Yes

Are you currently eligible for or receiving Medicaid, SNAP (Supplemental Nutrition Assistance Program), Families First, public housing assistance, Section 8, National School Lunch Program or free/reduced lunch?

Yes

Are you currently employed?

Yes

How did you hear about GROWWTH?*

Other: Please specify

Thank you for your interest in GROWWTH!
Submitting this form allows our team to follow up with you.