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ARP Application

Please complete the form below. Required fields marked with an asterisk *
Child Lives With*
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Parent Information: Mother

State
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Marital Status
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Highest level of education completed
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Parent Information: Father

State
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Marital Status
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Highest level of education completed
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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
Are you currently working with DCF?*
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If YES, Do you have an assigned case worker? (Reason for referral must be documented and signed by the DCF agent)
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Upload reason for referral document if necessary
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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)*
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Upload home survey documentation if necessary
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or drag it here.
Is the child's family migrant? (A copy of the Certificate of Eligibility must be on file.)*
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Certificate of Eligibility upload if necessary
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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)?*
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Is the child developmentally or academically delayed based on assessments? (Assessments must be in the child's file)*
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Assessment upload if necessary
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or drag it here.
Were either parent under the age of 20 years when the child was born? (verify by including birthdate above)*
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Parent/Guardian Signature*
Signature Required

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