Grace Elementary Enrichment Program (GEEP) Application

Thank you for your interest in GEEP! Please fill out this form and submit.

General Information

To be filled out by parent/legal guardian.

Child's Name

Date of Birth

Age

School

Name of Parent/Legal Guardian

Address

Phone #1

Phone #2

This address will receive a confirmation email

Emergency Contact Information

To be used if parent/legal guardian is not available.

First Contact Name

Relationship to Child

Phone

Address

Second Contact Name

Relationship to Child

Phone

Address

Family Information

Some funding we may seek may require that we keep anonymous statistics regarding the children and families we serve. If you are willing to help us with this, please respond to the following questions. Your answers are anonymous and will not affect your child's participation in the GEEP program in any way.

Number of family members

Optional

Number of children in the household

Optional

Yearly family income

Optional

Please select one option.

Less than $14,570 $14,570 - $29,530 $29,530 - $37,010 $37,010 +

Employment of parent/guardian

Optional

Please select one option.

Full time Part time Unemployed

Has your family received any government aid in the last 12 months? (SNAP, WIC, Unemployment, Child Care Assistance, etc.)

Optional

Please select all that apply.

Yes No

If yes, are they sufficient in supporting your family?

Optional

Please select all that apply.

Yes No N/A

Have you received financial, food, or clothing assistance from any charitable organization within the last 12 months?

Optional

Please select all that apply.

Yes No

Have you volunteered within the last 12 months?

Optional

Please select all that apply.

Yes No

How many veterans are in your household?

Optional

In what age group are the adults in this household?

Optional

Please select one option.

20-29 30-39 40-49 50-55 Over 55

What are the ethnicities of members of your household?

Optional

Please select one option.

African American Hispanic/Latino Native Hawaiian American Indian Caucasian/Non-Hispanic Asian

Description

Thank you for your interest in GEEP! Please fill out this form and submit.

Grace Elementary Enrichment Program (GEEP) Application

Description

Please Fix the Following