EmailMeForm
BACK TO SCHOOL CLOTHING ASSISTANCE
Photo ID for the person applying
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Photo ID or birth certificates for ALL adults and children living in the household
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Proof of address – bill, bank statement, letter from SSA or JFS, etc.
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Enrollment letter for all children entering Kindergarten
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Income Verification (pay stubs, W-2, SSA / JFS letter, etc.)
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Parent / Guardian Information
Adult 1 - Full Name
Adult 1 - Email Address
Adult 1 - Relationship to Child
Adult 1 - Age
Adult 2 - Full Name
Adult 2 - Relationship to Child
Adult 2 - Age
Street Address
City
Primary Phone
Alternate Phone
Child Information
Number of Children
Please select
1 Child
2 Children
3 Children
4 Children
5 Children
6 Children
7 Children
Child 1 Name
Child 1 School Attending
Child 1 Age
Child 1 Sex
Child 1 Grade
Child 2 Name
Child 2 School Attending
Child 2 Age
Child 2 Sex
Child 2 Grade
Child 3 Name
Child 3 School Attending
Child 3 Age
Child 3 Sex
Child 3 Grade
Child 4 Name
Child 4 School Attending
Child 4 Age
Child 4 Sex
Child 4 Grade
Child 5 Name
Child 5 School Attending
Child 5 Age
Child 5 Sex
Child 5 Grade
Child 6 Name
Child 6 School Attending
Child 6 Age
Child 6 Sex
Child 6 Grade
Child 7 Name
Child 7 School Attending
Child 7 Age
Child 7 Sex
Child 7 Grade
Income & Expenses (monthly amounts)
Employment gross income
ADC / Kinship
Food Stamps
Child Support
Unemployment
SSI / SSD
Other
Rent / Mortgage
Utilities / Electric
Phone / Cable / Internet
Transportation
Child Support
Credit Card / Loans
Food / Taxables
Other
Employment Information
Company Name
Length of Employment
If not working, how long has client been off work?
Additional Information / Comments / Special Circumstances
Release of Information
Client Name
Date of Birth
Address
Social Security Number
Guardian Name
Guardian Address
Protected Information Authorized for Communication
I authorize Fairfield County 2-1-1 and Charity Newsies to communicate about the following protected information:
JFS Benefits / Community Services
Housing / Homelessness
Financial Assistance
JFS Protective Services, Child or Adult
Counseling Attendance / Progress
Utility Bill Information
All Outstanding Debt
Other
Information to be Released from Fairfield County 2-1-1
I authorize Fairfield County 2-1-1 and Charity Newsies to communicate about the following protected information:
Referred Service
Other — Financial / Income Information
Demographic Information
Purpose of Information Exchange
Time Period for Information Collected
I authorize Fairfield County 2-1-1 and Charity Newsies to communicate about the following protected information:
Facilitate 2-1-1 Service
Facilitate Case Management
I authorize Fairfield County 2-1-1 and Charity Newsies to communicate about the following protected information:
Current Information
In the Last 6 Months
In the Last 12 Months
In the Last 5 Years
Signatures
Client / Guardian Name (Please Print)
Date
Preferred Contact Method
Mail.
Call.
Text.
Signature
Clear
