First Name: First Name:
Last Name: Last Name:
Date of Birth: Date of Birth
Gender: Gender:: male female
Does your child have special needs? Does your child have special needs?: no yes
If yes, please explain: If yes, please explain:
Mother's Name: Mother's Name:
Father's Name: Father's Name:
Address: Address:
Address 2: Address 2:
City: City:
State: Select StateAL - AlabamaAK - AlaskaAZ - ArizonaAR - ArkansasCA - CaliforniaCO - ColoradoCT - ConnecticutDE - DelawareDC - District Of ColumbiaFL - FloridaGA - GeorgiaHI - HawaiiID - IdahoIL - IllinoisIN - IndianaIA - IowaKS - KansasKY - KentuckyLA - LouisianaME - MaineMD - MarylandMA - MassachusettsMI - MichiganMN - MinnesotaMS - MississippiMO - MissouriMT - MontanaNE - NebraskaNV - NevadaNH - New HampshireNJ - New JerseyNM - New MexicoNY - New YorkNC - North CarolinaND - North DakotaOH - OhioOK - OklahomaOR - OregonPA - PennsylvaniaPR - Puerto RicoRI - Rhode IslandSC - South CarolinaSD - South DakotaTN - TennesseeTX - TexasUT - UtahVT - VermontVA - VirginiaWA - WashingtonWV - West VirginiaWI - WisconsinWY - Wyoming
Postal Code: Postal Code:
Phone #1: Phone #1
Phone #1 Type Cell Home Work
Phone #2: Phone #2
Phone #2 Type Cell Home Work
Phone #3: Phone #3
Phone #3 Type Cell Home Work
Email: Email
School District: School District:
Total Number in Family: Total Number in Family:
Number of Children Under Age 5: Number of Children Under Age 5:
Name of Child Under 5: Name of Child Under 5:
Head Start: Head Start:: no yes
Duration (head start): Duration (head start)Home-BasedPart-DayFull-Day
Early Head Start: Early Head Start:: no yes
Duration (early head start): Duration (early head start)Home-BasedPart-DayFull-Day
Wages: Wages:
Unemployment: Unemployment:
College Grants: College Grants:
OWF: OWF:
SSI: SSI:
Child Support: Child Support:
Child Care: Child Care:: no yes
Duration (child care): Duration (child care)4 Days/Week5 Days/Week
Before and After School: Before and After School:: no yes
Duration (before and after school): Duration (before and after school)AM onlyPM onlyBoth AM & PM
Summer Programs: Summer Programs:: no yes
Location:: Location::
How did you hear about our programs? How did you hear about our programs?: Referred by Agency Friend/Family Saw The Center My Child's School Website Movie Theatre Other
Has your child received services from Child Focus in the past? Has your child received services from Child Focus in the past?: no yes
