Reduced Fee Questionnaire

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

How many people (including yourself) are in your household? *

What is the parent/child ratio in your household? (Ex: 2:5) *

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? *

Which class are you completing this Reduced Fee Questionnaire for? *

Circle of Security Children in Between Both

Client Name *

First

Last

Phone Number *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

How did you hear about us? *

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

​Reduced Fee Questionnaire

Reduced Fee Questionnaire