Legacy of Hope Austin/2learn2dream toll free 866-HOPEATXwww.legacyofhopeaustin.org
Please describe your child’s
school history, including details that would be important for ourteam to know in order to provide the best care for your child: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________
The following information is collected strictly for Legacy of Hope Austin for statistical purposes. Thisinformation helps Legacy of Hope Austin address questions grantees and donors may have regarding diversity,socio-economic status, etc. Your information will be kept confidential. Thank you for your willingness and honesty
One or Two Parent Household:____________3.
Total number of children in family (including child(ren) with special needs):_____________5.
Family’s Income Level (circle one):
Mother’s Highest Completed Educational Level:
Father’s Highest Completed Educational Level:
Do you currently receive services from the Division of Services for People with Disabilities?Do you currently receive aid from your school district for their lunch program or any othersupport program?Please explain how you think this program might strengthen your family: ______________________________________________________________________________Please indicate, between 1 and 10, the average stress level on your family as a whole: ________