Step
1
of
5
- Start
0%
Before starting this form, we encourage you to gather the following documents, if you have them:
Continuum ID Card
Social Security Card
Shelter Letter
Health Insurance Card
State Issued ID or Passport
Food Stamp Award Letter
Most Recent Income Statement (social security, disability, tax documents and/or pay stub)
Name
(Required)
First
Middle
Last
Are you 18 years of age or older?
(Required)
Yes
No
Are you pregnant?
(Required)
Yes
No
NA
Date of Birth
(Required)
MM slash DD slash YYYY
Phone Number
(Required)
Are You Currently Homeless
(Required)
Yes
No
Address
(Required)
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Is this in Jefferson County?
(Required)
Yes
No
Please upload a photo of your continuum ID card if you have one
Max. file size: 8 MB.
Upload an image of your social security card, if you have one
Max. file size: 8 MB.
Please upload a photo of your shelter letter if you have one
Max. file size: 8 MB.
If you are unable to upload these documents, please come to the Cooper Green enrollment department Monday Friday 7 a.m. – 4 p.m.
Do you have health insurance?
(Required)
Yes
No
Please upload a photo of the front of your insurance card if you have one
Max. file size: 8 MB.
Please upload a photo of the back of your insurance card if you have one
Max. file size: 8 MB.
Please upload an image of your social security number if you have one
Max. file size: 8 MB.
Please upload a photo of the front of your state issued ID or passport if you have one
Max. file size: 8 MB.
Please upload a photo of your social security card if you have one
Max. file size: 8 MB.
If you are unable to upload these documents, please come to Cooper Green enrollment department Monday – Friday 7 a.m. – 4 p.m.
Do you receive food stamps?
(Required)
Yes
No
Please upload a photo of your award letter if you have one
Max. file size: 8 MB.
Please upload a photo of the front of your state issued ID or passport if you have one
Max. file size: 8 MB.
Please upload a photo of your social security card
Max. file size: 8 MB.
If you are unable to upload these documents, please come to Cooper Green enrollment department Monday – Friday 7 a.m. – 4 p.m.
Do you have income?
Yes
No
Do you have a minor child in custody?
(Required)
Yes
No
Please upload a photo of your most recent income statement (social security, disability, tax documents and/ or pay stub) if you have one
Max. file size: 8 MB.
Please upload a photo of the front of your state issued ID or passport if you have one
Max. file size: 8 MB.
Please upload a photo of your social security card if you have one
Max. file size: 8 MB.
If you are unable to upload these documents, please come to the Cooper Green enrollment department Monday Friday 7 a.m. – 4 p.m.