2024 Family Supports Program Application
If you are enrolled on a Medicaid Waiver, you are not eligible for the Family Supports Program. Please contact your Support Administrator as you may be eligible for similar services. If you are new to Cuyahoga DD or are uncertain about your eligibility status, please contact us at 216-736-2673 or Intake@cuyahogabdd.org.
Name of Eligible Person
*
First Name
Last Name
Date of Birth of Eligible Person
*
-
Month
-
Day
Year
Date
Does this eligible individual live with the family?
*
Yes
No
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian or Eligible Person Email
This is required. Please enter an email.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
*
Cell Phone
Resident of Cuyahoga County?
*
Yes
No
Only individuals living in Cuyahoga County are eligible for the Family Supports Program. Are you a resident of Cuyahoga County?
*
Yes
No
Foster Family
*
Yes
No
Individuals in foster care do not qualify for the Family Supports Program. Are you a foster family?
*
Yes
No
Is the person eligible for the Family Supports Program age 17 or younger?
*
Yes
No
Enter the total, annual taxable income for your household last year. (This is only required if the eligible person is 17 years of age or younger.)
(You must enter a dollar amount.)
Eligible Person Race:
*
White/Caucasian
Black/African American
American Indian or Alaskan Native
Asian
Native Hawaiian and Other Pacific Islander
Two or more races
Prefer not to answer
Eligible Person Ethnicity
*
Hispanic or Latino
Non-Hispanic or Latino
Prefer not to answer
Please verify that you are human
*
Submit
Enter the total, annual taxable income for your household last year. (This is only required if the eligible person is 17 years of age or younger.)
(You must enter a dollar amount.)
Enter the total, annual taxable income for your household last year. (This is only required if the eligible person is 17 years of age or younger.)
(You must enter a dollar amount.)
Should be Empty: