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ARP Application

Please complete the form below. Required fields marked with an asterisk *
Child Lives With*
Answer required for "Child Lives With"

Parent Information: Mother

State
Answer required for "State"
Marital Status
Answer required for "Marital Status"
Highest level of education completed
Answer required for "Highest level of education completed"

Parent Information: Father

State
Answer required for "State"
Marital Status
Answer required for "Marital Status"
Highest level of education completed
Answer required for "Highest level of education completed"

General Information

Does your child qualify for the free lunch program? (must have completed application for State At Risk funding or Child Nutrition Benefits)*
Answer required for "Does your child qualify for the free lunch program? (must have completed application for State At Risk funding or Child Nutrition Benefits)"
Are you currently working with DCF?*
Answer required for "Are you currently working with DCF?"
If YES, Do you have an assigned case worker? (Reason for referral must be documented and signed by the DCF agent)
Answer required for "If YES, Do you have an assigned case worker? (Reason for referral must be documented and signed by the DCF agent)"
Upload reason for referral document if necessary
Answer required for "Upload reason for referral document if necessary"
or drag it here.
Is the primary language spoken in the home a language other than English? (as documented by the State provided oral assessment or other standardized test) (attach documentation of home survey, assessment, and services)*
Answer required for "Is the primary language spoken in the home a language other than English? (as documented by the State provided oral assessment or other standardized test) (attach documentation of home survey, assessment, and services)"
Upload home survey documentation if necessary
Answer required for "Upload home survey documentation if necessary"
or drag it here.
Is the child's family migrant? (A copy of the Certificate of Eligibility must be on file.)*
Answer required for "Is the child's family migrant? (A copy of the Certificate of Eligibility must be on file.)"
Certificate of Eligibility upload if necessary
Answer required for "Certificate of Eligibility upload if necessary"
or drag it here.
Is your child receiving any special services, i.e. speech therapy, learning disabilities, mentally handicapped, other (Do they have an IEP Individual Education Plan)?*
Answer required for "Is your child receiving any special services, i.e. speech therapy, learning disabilities, mentally handicapped, other (Do they have an IEP Individual Education Plan)?"
Is the child developmentally or academically delayed based on assessments? (Assessments must be in the child's file)*
Answer required for "Is the child developmentally or academically delayed based on assessments? (Assessments must be in the child's file)"
Assessment upload if necessary
Answer required for "Assessment upload if necessary"
or drag it here.
Were either parent under the age of 20 years when the child was born? (verify by including birthdate above)*
Answer required for "Were either parent under the age of 20 years when the child was born? (verify by including birthdate above)"
Parent/Guardian Signature*
Signature Required

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