New Parent or Guardian Registration

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Keep Kids Warm / AAC Winter Clothing Program
Application Form - Belleville

First Name*

Last Name*

Address*

Unit / Apartment / Additional Address Information:*

Email Address*

Confirm Email Address*

Phone*

Pickup Location

Parent / Guardian Information

Please upload a photo / scan of one piece of government issued identification for the parent / guardian completing this application. The name on the identification MUST be the same as the information provided in this application.*

You will need to log in using your username and password to fill out forms for any children.

User Name (Your Email Address)*

Password*

Re-Enter Password*

Digital Signature

By typing your name in the box below, you are providing a digital signature. By providing your digital signature, you are giving consent to the Keep Kids Warm / AAC Program to use the information provided for the sole purpose of determining eligibility and program administration.*

Enter the code displayed*

New Parent or Guardian Registration

Keep Kids Warm / AAC Winter Clothing Program Application Form - Belleville

Parent / Guardian Information

Keep Kids Warm / AAC Winter Clothing Program
Application Form - Belleville