* Required Fields
Child's Name:
Birthdate:
Sex: Male Female
Parent/Gaurdian:
Phone:
Email Address:
Address:
Babysitter:
Annual Income (last 12 months):
Are you currently employed: Yes No
Number of members in family:
List language(s) spoken in home:
Mother's highest grade completed in school:
Father's highest grade completed in school:
Mother's age at birth of first child:
Have you or any of your children been diagnosed with a handicap? Yes No
Please Explain:
Have you or any of your children had a long-term or chronic illness? Yes No
Do any of your children receive special services? Yes No
Has your child experienced death of a parent or sibling? Yes No
Are you a single parent? Yes No
Do you live in a rural area? Yes No
How did you hear about BHCS? Benton Spirit Herald Palladium Movie theater ad WVBH 105.3 FM WSMK 99.1 FM Direct mailer Handout Billboard Event Friend/Family Other
Once you have completed all required fields and agree to the terms (by checking the box the box below) your application is now ready to submit! Please click "Submit Application" button. A confirmation email will be sent to the email address listed under legal guardian one. By checking this box, I certify that all information provided in this application and in all accompanying forms is true, accurate, and complete.
*You must first check the box above in order to submit your application.
