FLDOH - SLVP Request Tracking System

*Select your County of residence:

*Please type your zipcode

Parent or Guardian Information:

*First Name:

Middle Name:

*Last Name:

*Email Address:

*Confirm Email Address:

*Phone Number:

Financial Eligibility:

*Does the child have a Medicaid number?

If you don't know your child's number, visit https://myaccess.myflfamiliies.com
or call 850-300-4323

Child Information:

NOTE: Only children ages 0 - 4 as of the date of application are eligible for vouchers.

*First Name:

Middle Name:

*Last Name:

*Date of Birth:

*Sex:

*Is the child of Hispanic Latino and/or Spanish Origin:

*Race (Check all that apply):

White

Asian

Black or African American

Hawaiian or Pacific Islander

Native American or Alaskan

Other

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