Please complete the entire application, for questions or comments please contact projectgives@bgcgh.org.

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* 1. Application Date: (Fecha de Aplicación:)

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* 2. Name:(Nombre)

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* 3. Email:(correo electrónico)

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* 4. Is your child a member of the Boys & Girls Clubs of Greater Houston? (¿Es su hijo/a miembro del Boys & Girls Clubs of Greater Houston?)

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* 5. If your child is a member, what site do they attend? (Si es miembro, ¿a cuál lugar asiste?)

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* 6. Are you an employee of the Boys & Girls Clubs of Greater Houston?(¿Es usted un empleado del Boys & Girls Clubs of Greater Houston?)

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* 7. Are you related to an employee of the Boys & Girls Clubs of Greater Houston? (¿Es usted familia de un empleado del Boys & Girls Clubs of Greater Houston?)

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* 8. Input demographic info below;

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* 9. Sex (Género)

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* 10. Age (Edad)

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* 11. Marital Status: (Estado Marital)

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* 12. Do you receive any Texas Benefits for yourself or your children? (¿Recibe algún beneficio del estado de Texas para usted o sus hijos?)(SNAP, TANF, WIC, Medicaid or CHIP)

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* 13. If you receive any of the above benefits please check all that apply: (Si usted recibe algún beneficio mencionado, favor de circular al que aplique)

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* 14. If you receive Medicaid or CHIP, or have private insurance please answer the following:(Si usted recibe Medicaid o CHIP, favor de responder a lo siguiente)

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* 15. If you have Texas Children’s Plan, please insert Texas Children’s Plan ID: (Si usted tiene Texas Children Plan, favor de escribir el número del plan)

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* 16. If you have Community Health Choice, Please insert Community Health Choice Plan ID: (Si usted tiene Community Health Choice, favor de escribir el número del plan)

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* 17. Please choose one of the following: Favor de escoger uno de los siguientes

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* 18. Where you currently impacted by COVID-19 due to one of the following? (¿Fue usted impactado por el COVID-19 por medio de lo siguiente?)

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* 19. Please list everyone who the applicant is legally responsible for including spouse and dependents. (Por favor escriba por quien el solicitante es responsable legalmente, incluyendo esposo/a y dependientes)

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* 20. Total  Family Household: (Total de Familiares en el Hogar)

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* 21. What is the current family income? (¿Cual es ingreso actual del hogar?)

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* 22. Do you have reliable transportation? (¿Tiene transporte confiable?)

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* 23. How were you referred? (cómo fue referido)

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