Goodside Cares Workflow

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Student Information / Información del estudiante

Student's Name / Nombre del estudiante*

First Name

Last Name

Student's Date of Birth / Fecha de nacimiento del estudiante*

District Name / Nombre del distrito*

School/Campus Name / Nombre de la escuela/campus*

Grade Level / Nivel de grado*

Is this student a U.S. Citizen? / ¿El estudiante es ciudadano estadounidense?*

Yes / Sí No / No

Parent/Guardian Information / Información del padre/tutor

Name of Parent/Guardian Filling Out Form / Nombre del padre/tutor completando el formulario*

First Name

Last Name

Relationship to Student / Relación del estudiante*

Primary Language Spoken by Parent/Guardian / Idioma principal hablado por el padre/tutor*

Email Address / Correo electrónico*

Phone Number / Número de teléfono*

HOUSEHOLD/IMCOME INFORMATION / INFORMACIÓN DEL HOGAR/INGRESOS

How many people live in the household, including the student? / ¿Cuántas personas viven en el hogar, incluyendo el estudiante? *

Is one or more parent/guardian unemployed? / ¿Uno o más de los padres/tutores están sin empleo?*

Yes / Sí No / No

Monthly Household Income (include everyone in the household) / Ingresos familiares mensuales (incluya a todos los miembros del hogar)*

Have you applied for Medicaid or CHIP for this student? / ¿Ha solicitado Medicaid o CHIP para este estudiante?*

Yes, child does not qualify / Si, el estudiante no califica Yes, application is pending / Si, la aplicación está pendiente No / No

Does the family receive services such as TANF, SNAP/Food Stamps, WIC? / ¿Recibe la familia servicios como TANF, SNAP/cupones para Alimentos, WIC?*

Yes / Sí No / No

Please upload proof of income received by anyone in the household with the student / Cargue un comprobante de ingresos recibidos por cualquier persona en el hogar con el estudiante

No File Chosen

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Signature of Parent/Guardian Filling out Form / Firma del padre/tutor completando el formulario*

[clear]

Use your mouse or finger to draw your signature above / Utilice el mouse o el dedo para dibujar su firma arriba

Submission Date/Time

Internal Processing

Support Team Staff*

First Name

Last Name

Date/Time*

Additional Upload if Available

No File Chosen

File uploads may not work on some mobile devices.

Ex. Recommendation letter from nurse, etc.

Approval Status*

Yes No

Approver's Name*

First Name

Last Name

Campaign Source

This hidden field has been added by Attribution to CRM Plugin to store Campaign Source in this Form's submission table

Campaign Medium

This hidden field has been added by Attribution to CRM Plugin to store Campaign Medium in this Form's submission table

Is your student uninsured? The Goodside Cares program is here to help!

¿Su estudiante no tiene seguro? ¡El programa Goodside Cares está aquí para ayudar!

Student Information / Información del estudiante

Parent/Guardian Information / Información del padre/tutor

HOUSEHOLD/IMCOME INFORMATION / INFORMACIÓN DEL HOGAR/INGRESOS

Internal Processing