Application Form Application Form Please tell us about what you need. We’re here for you. Have you received services at Community Action Marin before? Yes No Which services have you used? Child Development Program Head Start Enterprise Recovery Center CARE Outreach Teams LIHEAP SparkPoint Coaching Tax Assistance Are you a Marin County resident? Yes No What is your household’s gross monthly income? Are you looking for childcare or parenting support? Yes No Do you need services for an expectant mother? Yes No Are there children in your home from 0 (birth) - 12 years of age?* Yes No How many children do you have?12345 How old are they?Child #1Child #10123456789101112Child #2Child #20123456789101112Child #3Child #30123456789101112Child #4Child #40123456789101112Child #5Child #50123456789101112 Do you need assistance paying for energy for your home?(PG&E, wood or propane) Yes No Are you experiencing a housing, food, mental health, or other concern? Yes No First Name Last Name Date of Birth* MM slash DD slash YYYY (Required for Rental Assistance)Phone Number Email Address Street City StateStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code What is the best way to contact you? Phone Email Mail Δ