CLIENT ENROLLMENT FORM YOUR NAME AS AGENT OR REPRESENTATIVE * First Name Last Name Client Name * First Name Last Name Client Email * Client Phone (###) ### #### Recieve Texts? YES Client Eligibility Requirements * Please Check All That Apply Medicaid Foodassistance /EBT FreeBreakfast/lunchProgram Snap 2021 Pell Grant Recipient Federal Housing Veterans disability with survivor Pension SSI-Unemployment The client has been successfully enrolled.