P.O. Box 1696, Santa Cruz, CA 95061
CHILD’S INFORMATION
Child’ Name _________________________________________Age____________________
Address _____________________________________________Phone__________________
City ________________________________________________Zip Code________________
School__________________________________________ ____Grade__________________
Birthplace____________________________________________Birthdate_______________
Care Needed_________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Referred by ______________________________Date _____________Phone_____________
FAMILY INFORMATION
Name Address Birthplace
Father_______________________________________________________________________
Mother______________________________________________________________________
How long have you lived in Santa Cruz? ___________________________________________
Brothers, Sisters, and/or others living in the home:
Name Address Birthplace
1. __________________________________________________________________________
2.___________________________________________________________________________
3.___________________________________________________________________________
4.___________________________________________________________________________
Has any member of your family ever received help from Omega Nu?
If yes – name and year __________________________________________________________
INCOME INFORMATION
Employer Permanent/Seasonal Salary
Father________________________________________________________________________
Mother________________________________________________________________________
Other_________________________________________________________________________
Do you receive any additional aid? No_____ Yes_____ Source________________________
How much each month? __________________________________________________________
ADDITIONAL INFORMATION
Rent or House Payment/Month _________________________Food/Month_________________
Medical Expenses ___________________________________Other Large Expenses__________
______________________________________________________________________________
I agree that any pertinent information may be given to the authorized chairman of Omega Nu. I understand that this information will be kept confidential. I agree to hold free from liability for damage from any cause Sigma Alpha of Omega Nu, the High School District and or Elementary School District and any person, organization or association which may provide, in any part, such service.
Date_________________ Parent’s Signature__________________________________________