Only one person in the household needs to complete this registration form; we do not need registration forms for every person who lives in the household.

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* 1. Please enter your full name

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* 2. Please enter your address

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* 3. Please enter your phone number

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* 4. How many people aged 0-17 live in your household?

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* 5. How many people aged 18-26 live in your household?

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* 6. How many people aged 27-59 live in your household?

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* 7. How many people aged 60+ live in your household?

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* 8. What is your household's total monthly income?

To be eligible to receive the hygiene and cleaning products at the event, your total household income must be at or below 125% of the federal poverty guidelines and you must provide proof of income to complete your registration. You can either bring the documents with you to the event or you can email them to the email address listed below.

For questions please contact Venango County CSS office at 814-432-9767 or contact Beki King at rebekah.king@venangocountypa.gov

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