Name: Polk County (Ankeny Area) Back-To-School Mini Rally https://familieshelpingfamiliesofiowa.org/?wpforms_form_preview=1640
Start: 2024-08-02T17:00:00-05:00
End: 2024-08-02T19:00:00-05:00
Location: Four Oaks Training Center

Name *

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Child's Age *

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Please Select Grade Level of Child *

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Child's Medicaid Number *

Please note Medicaid Numbers have 7 letters, 1 number.

Status of Child *

Will this child need a Haircut Voucher from Great Clips? *

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Child's County *

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

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Caregiver's Information *

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Name *

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Address *

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County *

Case Worker's Name & Information *

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Polk County (Ankeny Area) Back-To-School Mini Rally https://familieshelpingfamiliesofiowa.org/?wpforms_form_preview=1640

August 2 @ 5:00 pm - 7:00 pm

Details

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