Legacy of Hope Austin 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 (
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? Y/NDo you currently receive aid from your school district for their lunch program or any othersupport program? Y/NPlease 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: ________