Eastern Idaho Community Action Partnership

Font-size: Reset A A

Sub Navigation

357 Constitution Way
Idaho Falls, ID
83402
info@eicap.org
208-522-5391

Child's Name:*

Child's Birthday:*

Gender:*

Female

Male

Address

Line 1:*

Line 2:

City:*

State:*

Zip Code:*

Phone Number:*

Parent or Guardian Information

Parent 1:*

Parent 2:

Address (if Different)

Parent's Line 1:

Parent's Line 2:

Parent's City:

Parent's State:

Parent's Zip Code:

Number in Family:*

Annual Income:*

Please check any of the following boxes that apply to your Family:

TANF

SSI

Homeless Shelter

Foster Child

Identified Disability

Suspected Disability

More information will be mailed out to you.