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JULY SAVES 1002 East Ave. Q-12 Palmdale, CA 93550 661/267-5191 Fax: 661/267-5274 — OVER — Applicant Must Complete Both Sides of Application Participant Application (All information must be filled in completely) Date Referred by: Primary Applicant: Date of birth: / / Social Security XXX-XX- Drivers license/ID Address: City: State: Zip: Telephone: Alt. telephone: Disability? Yes No Military Service? Yes No If yes, what branch of service: 2nd Adult: Date of birth: / / Social Security XXX-XX- Drivers license/ID Disability? Yes No Military service? Yes No If yes, what branch of service: 3rd Adult: Date of birth: / / Social Security XXX-XX- Drivers license/ID Disability? Yes No Military service? Yes No If yes, what branch of service: 4th Adult: Date of birth: / / Social Security XXX-XX- Drivers license/ID Disability? Yes No Military service? Yes No If yes, what branch of service: Child’s Name Date of Birth (MM/DD/YYYY) Gender Disability? 1. .M .F .Yes .No 2. .M .F .Yes .No 3. .M .F .Yes .No 4. .M .F .Yes .No 5. .M .F .Yes .No 6. .M .F .Yes .No 7. .M .F .Yes .No South Antelope Valley Emergency Services ---PAGE BREAK--- Revised 6/20/2018 Sources of Income: Please fill in the amount of income received in each category below. Example: $135.00 SSI + $ 811.00 Disability = $946.00 Total $ GR $ CalWorks $ Social Security $ Disability $ Alimony $ Employment $ SSI $ Pension $ Unemployment $ SSA $ TANF $ Child Support $ No Income $ KinGap $ Foster Care $ CalFresh $ Other ( ) Add ALL income for Total Household Income: $ Are you of Hispanic/Latino origin? Yes No Race/Ethnicity (Information used for funding reports only) White Black/African American Asian American Indian/Alaska Native Native Hawaiian/Other Pacific Islander American Indian/Alaska Native & White Asian & White Black/African American & White American Indian/Alaska Native & Black/African American Other Multi-Racial (Information used for funding reports only) Mexican/Chicano Puerto Rican Cuban Other Highest Level of Education (Information used for funding reports only) Never finished High School High School graduate GED Some college Associates Degree Bachelors Degree Graduate School and/or higher CLIENT’S SIGNATURE: DATE: STAFF NOTES: STAFF-please check one EL VL L Staff signature: Date: