Yes!
I’d like
more information on low-cost health care coverage
I’d like to
set up an appointment to apply for health care coverage
Please
have someone from a community organization or health plan call to help
me apply.
I understand that all help
is free of charge. All information is confidential.
Parent/Guardian’s Last Name ______________________ First
Name___________________
Address_________________________________________________
Zip______________
Phone #
__________________________ Message Phone # _________________________
When is
the best time to call you? __________ (am) __________ (pm)
Name of
school ______________________________________
The
language I speak best is (English, Cantonese, Spanish, etc)
_________________________
