Child's Name *

First Name

Last Name

Child's Date of Birth *

MM

DD

YYYY

Child's Sex *

Male

Female

Child's Name

First Name

Last Name

Child's Date of Birth

MM

DD

YYYY

Child's Sex

Male

Female

Parent/Legal Guardian Name *

First Name

Last Name

Phone

(###)

###

####

Parent/Legal Guardian Name

First Name

Last Name

Phone

(###)

###

####

Masonic Member's Name

First Name

Last Name

Masonic Member's Date of Birth

MM

DD

YYYY

Masonic Member's Relationship to Child/Young Adult *

Father

Grandfather

Great-Grandfather

Uncle

Other

No Masonic Affiliation

Needs related to request. *

Check all that apply.

Grocery Assistance

School Supplies

Medical or Adaptive Equipment Cost

No Computers in Home

Cost of Extracurricular Activities

Clothes Assistance

Medical Expenses

Medication Expenses

No Internet Access in Home

Childcare Expenses

Therapy Expenses

Evaluation Expenses

Counseling Expenses

Dental Expenses

Other

Name of Person Completing Application *

First Name

Last Name

How did you hear about IMCAP?

Family Member

Mason

IMOS

Other