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Online Learning
Family Education
Circle of Security
>
COS Missoula Registration
COS Flathead Registration
Children in Between
>
CIB Registration
Family Education Workshops
Mending Broken Hearts
Connection Cafes
Resources
UM Workshops
Events
Cabin Fever
PLAY
Exhibit Rentals
Community Partnerships
Donate
ABOUT US
Contact
Staff
Board of Directors
Parent Educators
Childcare Providers
Join Our Team
Our New Home
The following questionnaire is for Circle of Security and Children in Between.
Please answer the following questions regarding your household circumstances to be considered for a reduced fee for Families First Learning Lab. Clients who qualify at 150% or less of Federal Poverty Level will qualify for a reduced fee. More information on Federal Poverty Level guidelines can be found at:
https://aspe.hhs.gov/poverty-guidelines
Reduced Fee Questionnaire
*
Indicates required field
Client Name
*
First
Last
Email
*
How many people (including yourself) are in your household?
*
What is the parent/child ratio in your household? (Ex: 2:5)
*
Which class are you completing this Reduced Fee Questionnaire for?
*
Circle of Security
Children in Between
Both
What is your annual household income?
*
(Please include income if one of your family members is contributing through a job elsewhere)
What, if any, other resources does your family benefit from? (tribal benefits, child support, retirement, pension, savings accounts, family support, etc.) How much do you receive from these sources?
*
Do you or your child(ren) currently receive public assistance (SNAP, TANF, Medicaid/HMK, WIC, LIEAP, etc.)?
*
Yes
No
If yes to receiving public assistance, which programs do you use?
*
If class payment will be billed through CFS, Please provide us with your case worker's name and phone number.
*
Signature & Date
*
By entering your name above, you are signing that all the information in this form is true and correct.
(Please Sign Name & Date)
Submit