Child's Information

How did you hear about our services?

Are you the child's parent/guardian?

You answered no. What is your name and relationship to the child?

Child's First Name

Child's Middle Initial

Child's Last Name

Child's Date of Birth

Child's Gender

Street Address

Street Address Line 2

City

State

Zip Code

Medical Assistance Number, if applicable

Last 4 digits of Child's Social Security Number

Child's Ethnicity

Child's Race

Child's Citizenship Status

Child's Living Status

Other Living Status (Please Specify)

Is this child in Foster care, Kinship care, or another arrangement where Child Protective Services may be involved?

Parent/guardian has educational rights?

Child's Primary Language

Other Primary Language (Please Specify)

Has your child received early intervention or special education services previously?

Is your child currently attending daycare/preschool?