Family Access Membership Application

Solicitud de Membresía de Accesso Familiar En Español

Primary Adult

Primary Member*

First Last

Contact Email*

Contact Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Family Member 2

Adult 2

First Last

Adult 2: Email

Phone

Relationship to Adult 1

Child 1

Child 1 Name*

First Last

Child 1: Birthdate**

Child 2

Child 2 Name

First Last

Child 2: Birthdate

Child 3

Child 3 Name

First Last

Child 3: Birthdate

Child 4

Child 4 Name

First Last

Child 4: Birthdate

Child 5

Child 5 Name

First Last

Child 5: Birthdate

Child 6

Child 6 Name

First Last

Child 6: Birthdate

Proof of Eligibility

-- Please upload an image of your photo ID*

Please upload an image of your photo ID**

Accepted file types: jpg, jpeg, gif, png, pdf, heic, Max. file size: 50 MB.

-- Please upload an image of your photo ID*

Please choose one of the following and upload an image below**

WIC Card

Link Card

Access DuPage Card

Other State or Federal EBT Card

Please upload an image of a qualifying item**

Accepted file types: jpg, jpeg, gif, png, pdf, heic, Max. file size: 50 MB.

-- Please upload an image of a qualifying item*

Thank you!

After you submit your application, you will receive a phone call within 5 business days to complete your membership. Your membership is not complete until payment is made over the phone and you receive your digital membership cards in your email.

Family Access Membership Application