Skip to Content
Menu
Home
Programs
Child Care & Education
Community & Rural Development
Financial Wellness & Workforce Development
Home Repair Needs
Housing Assistance
International Programs
Senior Services
Transportation
Utility Payment Assistance
All Programs
About
Contact
Donate
News
Jobs
1-800-775-9767
Search
Search
CHIP Referral
First Name
*
Last Name
*
Phone
*
Address
*
City
*
Do you live within city limits?
Yes
No
County of residence
*
Allen
Crawford
Erie
Hancock
Huron
Lorain
Lucas
Ottawa
Putnam
Sandusky
Seneca
State
*
Zip Code
*
Email
*
Ownership (Select one)
*
Own
Rent
Land Contract
What type of home do you live in?
Single family
Mobile home
Other
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
I would like to receive an application
Please email me an application
Please send me an application by mail
I consent to receive text messages from GLCAP
Yes