ACT Pass Application

Primary Account Name*

First Name Last Name

Primary Account Email*

Address*

Address Line 1 Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Household Size*

Number of Children under 19 Years of age in household*

Is there a single parent in the household?*

Yes
No

Children's Grade Level

Preschool
K+
3rd+
Middle School
High School
Not Applicable

Select all that apply.

Do you and/or your household qualify for Free and Reduced Lunch or other public assistance programs?*

Household Annual Income Level*

(Include income from work, welfare, child support, alimony, pension, social security and disability, and any other sources)

Annual Income

How did you hear about the ACT Pass program?

While household income is a major factor, we recognize other circumstances affect families’ economic realities. Please write a 1-2 sentence statement clarifying your need for economic assistance for CTC Programs this season. You may also inform us of any additional barriers for your family, including transportation, language, and/or special needs.

Please submit your application. Watch the email given above for further information within 3 business days

Name

This field is for validation purposes and should be left unchanged.

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