Please fill out all parts of this application so we may properly assess your child’s need for a bed. APPLICATION MUST BE RETURNED BACK TO _________________BY WEDNESDAY, JANUARY 8, 2025 .
*Please note: some of the information gathered is for statistical purposes, please answer honestly to help us identify the population we are seeking to help. Information provided is confidential and is viewed only by the selection committee.
GUARDIAN’S NAMES ___________________Relationship to child
Mailing Address City, Sate Zip
Home phone Work Phone Cell Phone
E-mail ADDRESS County of residence
List all children in the household and indicate which child/children requesting a bed.
Name
School Name
DOB
Gender
Pajama size
Bed Request Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
MULTIPLE REQUESTS FOR ONE FAMILY DOES NOT GUARANTEE ALL APPLICANTS WILL RECEIVE A BED.
Number of adults over 18 in the household number of those adults employed
Total annual household income (You must meet income guidelines to qualify for a bed. See Page 2)
ARE YOU OR ANY MEMBER OF YOUR HOUSEHOLD CURRENTLY SERVING OR PREVIOULY SERVED IN THE MILITARY? Y/N
Number of bedrooms in the house Number of beds in the house
Describe briefly the current sleeping arrangements of the children currently living in the house
I certify all information in this application is true
__________________________________________________________________ _______
Guardian Signature Date
Additional Information and Instructions
Please understand not all applicants will receive a bed.
Only school age children (youth) who are currently in school are eligible to apply.
There is only one design for beds (you may not make special requests, unless there is a physical disability).
Two weeks after the application deadline a determination will be made. We will contact you with a pick up date and location (do not contact us).
Please fill out all information honestly and to the best of your ability. Please provide accurate contact information.
It is your responsibility to notify us if your contact information changes. Please notify your school principal if any of your information changes. (failure to do so may result in a loss of awarded bed)
Incomplete applications will not be considered.
You will be expected to pick up your bed if you are chosen. (if you are unable to do so, please contact your school principal).
Income guidelines are used to determine eligibility. Eligibility is determined by timely submission, income, age of child, need.
Applications should be turned into your schools office by to be considered.
*Income Guidelines, you must be at or below the stated income for your family size.
For families with more than 8 persons, add $4,540 for each additional person.
SIZE OF FAMILY
ANNUAL INCOME
2
$20,440
3
$25,820
4
$31,200
5
$36,580
6
$41,960
7
$47,340
* poverty guidelines effective JANUARY 2024.
