Your Information:




Student Information:




























Parent (s) or Guardian (s) Information:















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Household Information
(Note: This information is collected and used solely for grant writing purposes)
Student Lives with: MomStep-MomDadStep-DadGrandparentOther
Annual Income Level (check one)$0 to $5,000$30,001 to $35,000$60,001 to $70,000$5,001 to $10,000$35,001 to $40,000$70,001 to $85,000$10,001 to $15,000$40,001 to $45,000$85,001 to $100,000$15,001 to $20,000$45,001 to $50,000$100,001 to $125,000$20,001 to $25,000$50,001 to $55,000$125,001 to $150,000$25, 001 to $30,000$55,001 to $60,000$150,001+





Is anyone in your household 65 years or older? YesNo



Is anyone in your household handicapped? YesNo

Is anyone in your household a Veteran? YesNo


Once you complete the enrollment application, you will be taken to the payment area.

If you see the message that your enrollment application has been sent, please click this link to complete your payment.