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Household Income Survey (English)

Household Income Survey (Spanish)

Please note, while completing this form is not mandatory, it is helpful for charter schools and districts to communicate the importance of collecting the information to their school families. This information will affect grant funding eligibility, how the charter school is represented in the media, and the charter school’s comparison to other similar schools in the annual report card.

We do encourage families to complete the form as your children may be eligible for reduced vendor rates, athletic fees, after-school program fees.

• Do I need to fill out a survey for each child?  No. Use one survey for all students in your household. We cannot approve an application that is not complete so be sure to fill out all required information. Return the completed application by email to April Tubbs at  or mail to TEACH-NW, ATTN: April Tubbs, P.O. Box 70365, Springfield, OR 97475

• My family needs more help.  Are there other programs we might apply for?  To find out how to apply for other assistance benefits, contact your local assistance office or call 2-1-1- or 1-800-SAFENET (723-3638). For food assistance call 1-866-348-6479 (1-866-3-HUNGRY).  In the summertime, Text “FOOD” to 877877 or visit  for free summer meal options in your area.

If you have other questions or need additional assistance, call April Tubbs via email at

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