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Adult 1/Self

Adult 2

Child 1

Child 2

Child 3

Yes No Self Spouse Parent

Yes No Self Spouse Parent

Yes No Self Spouse Parent

Yes No Self Spouse Parent

Yes No Self Spouse Parent

55

Current or past U.S. Military Service for adults, spouse or child’s parents?

56

Ethnicity (race): (optional)

57

In school full time?

58

Living away from home?

SECTION 7

Continued

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

SECTION 8

Information Release (Optional).

59 If family member cannot get no-cost Medi-Cal but may be able to get low-cost health care coverage,

can the local welfare office send this form to the Healthy Families Program?

Yes No

60

I got help from (give name of person)

when I

filled out this application. I agree that the local welfare office may give them information about the status of this application. Applicant please initial

SECTION 9

Signature and Certification.

61 I declare under penalty of perjury under the laws of the State of California that the answers I have given in this

application, and the documents given are correct and true to the best of my knowledge and belief.

I declare that I have read and understand the application instructions, the declarations, and all information printed on this application.

Signature

Date

Signature of person helping Applicant fill out the form

Telephone Number

Relationship to Applicant

Date

Signature of person acting for Applicant/Beneficiary

Telephone Number

Relationship to Applicant

Date

Witness Signature (If person signed with a mark)

Date

For information about any of the following programs, check the box(es) below and information will be sent to you. See the Medi-Cal brochure, “Health Care for Families with Children” or visit our website, www.dhs.ca.gov

Personal Care Service Program (PCSP). A program for in-home care.

Access for Infants, and Mothers (AIM). A program to help pregnant women with moderate income obtain health care.

Woman, Infants and Children Nutrition Program (WIC). A nutrition program for pregnant and postpartum women and children under 5.

Family Planning Child Health and Disability Program (CHDP). Preventive healthcare for children and youth.

Do you want your children or youth referred to the CHDP program?

Yes

No

MC 210 08/01 APPLICATION

A4

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