CHIP Referral | Great Lakes Community Action Partnership

First Name *

Last Name *

Phone *

Address *

City *

Do you live within city limits?

Yes
No

State *

Zip Code *

Email *

Ownership (Select one) *

What type of home do you live in?

Have you applied for CHIP before?

Yes
No

How many people 18 and over are there in the household? *

Income for all occupants over 18 years old (Select all that apply)

Self-Employed
Employed
Social Security\SSI\SSD
Public Assistance- ADC\TANF
Unemployment
Workers Compensation
Child Support
Pensions
No Income

How did you learn about our program?

Facebook, Instagram or other Social Media
Family or Friends
GLCAP Staff Member
Newspaper
Social Service Agency (Dept. of Job & Family Services, OhioMeansJobs, etc.)
Television or Radio
Other

Additional Comments