Self Enrollment

Individual Needing Assistance

If you are 18 yrs or older and need assistance, please fill this section out for yourself.

What Bexar County council district do you live in?

Name*

First Last

Date of Birth*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Email

If individual is a child, enter a parent/guardian's email.

Ethnicity*

Race*

Annual Household Income*

For the household where individual resides.

Currently receiving any of the following?*

Check all that apply.

Supplemental Nutrition Assistance Program (SNAP)
Child Support
Women Infants & Children (WIC)
Social Security Income (SSI)
NONE of the above
Other

What other assistance are you receiving?

Currently in school?*

Yes
No

If so, where?

Grade or Level

School District

If applicable

Diagnosis*

Or suspicion of a diagnosis.

Primary Care Physician*

If you don't have a PCP, enter NONE.

Date of last or upcoming visit.

Specialty Physicians

If you aren't seeing a specialty physicians, enter NONE.

Date of last or upcoming visit.

Insurance Carrier*

Check all that apply.

Private
Medicaid
CHIP
SKIP
CSHCN
Military
Other Public
Uninsured

Insurance Policy Number

Marital Status*

Employer*

If unemployed, enter NONE.

Military Status*

What branch of military?*

List all prescription medications the individual needing assistance is currently taking. Press plus button to add more lines.

What other agencies have you received assistance from, been in contact with, or are currently working with?

Enrollment Form - Self

Step 1 of 2

Individual Needing Assistance

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Self Enrollment