EmailMe Form - 2021-2022 Household Economic Survey

Please enter the number of people in your household, including all children and adults. *

Please enter the total annual income for all people in the household before any deductions for taxes, insurance, medical expenses, child support per year. *

$ Dollars . Cents

Student Information

	Student Name	School	Grade	Date of Birth
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I certify (promise) that all information on this application is true and that all income is reported. I understand that the school will receive federal and state funding based on the information provided. I understand that school officials may verify (check) the information.

Signature of Parent or Guardian *

First Last

Date Time *

MM / DD / YYYY

Phone

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