Name: Back-To-School Mini Rally: Scott County (Bettendorf Area)
Start: 2024-08-05T17:30:00-05:00
End: 2024-08-05T18:30:00-05:00
Location: The Fountains Senior Living Community

Child's Initials *

First

Last

I understand that falsifying Medicaid Numbers, and failing to provide accurate information may disqualify me from utilizing FHF services in the future? *

Yes

Child's Medicaid Number *

Please note the child's Medicaid Numbers will contain #######A (seven numbers and one letter)

Please Select Grade Level of Child *

Pre-K
Elementary School
Middle School
High School

Child's Age *

Sex

Male
Female
Other

Status of Child *

Childs County *

Shop at your local Goodwill Store Through our O Triple C Program. Each child receives a $30 voucher to get a head start on their school shopping. Will your child be using a O Triple C Clothing Voucher? *

Yes
No

Caregiver's Information *

First

Last

Phone

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email *

Email

Confirm Email

Caregiver's County *

Case Worker's Name and Information *

Phone *

Email

Back-To-School Mini Rally: Scott County (Bettendorf Area)

Details

Organizers

Venue