Antioch/Delta First 5 Center -  Registration Form  '22-23
Welcome to the Antioch and Delta First 5 Centers! First 5 California is a program that provides services to families with children zero to five as well as expectant caregivers. First 5 acknowledges that the parent/primary caregiver is the child's first and most important teacher.

We are currently offering both in-person and online children and parenting classes.
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REGISTRATION AND CLASS ENROLLMENT
All of our services are at no cost and available to Contra Costa County Residents. In order to participate at the center, this one-time registration form needs to be completed. Once completed, you will be able to participate in all services offered through the center. For more information, check out our social media on both Facebook and Instagram. If you have any additional questions, feel free to contact us 925-516-3880 and we will be happy to assist you.
How did you learn about the First 5 Center? *
Select the primary location where your family will be participating? *
Primary Adult - Parent/Guardian's First and Last Name *
Primary Adult - Parent/Guardian's Date of Birth *
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Email *
Mailing Address *
Phone number *
May we text this phone number?
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Family Role *
With what ethnic group(s) do you most identify? Check all that apply. *
Required
What language(s) do you speak at home? (Check all that apply) *
Required
Are you expecting a baby? If yes, when is your due date?
Car seats expire! Do you need car seat safety information?
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Second Adult - First Name and Last Name
Second Adult - Date of Birth
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/
DD
/
YYYY
Second Adult - Phone Number
May we text this phone number?
Clear selection
Second Adult - Email Address
Family Role
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With what race/ethnic group(s) does this person most identify?
May this person be contacted in an emergency?
Clear selection
May your child(ren) be released to this person?
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1st Child's Name and Last Name (Please only add children 0 to 5 yrs. old) *
1st Child's Gender
1st Child's Date of Birth
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DD
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YYYY
What is this child's race/ethnicity? *
Required
What language(s) does your child speak? (Check all that apply) *
Required
2nd Child's First and Last Name (Please only add children 0-5 yrs. old)
2nd Child's Gender
Clear selection
2nd Child's Date of Birth
MM
/
DD
/
YYYY
What is this child's race/ethnicity?
What language(s) does your child speak? (Check all that apply)
3rd Child's First and Last Name (Please only add children 0-5 yrs. old)
3rd Child's Gender
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3rd Child's Date of Birth
MM
/
DD
/
YYYY
What is this child's race/ethnicity? Check all that apply
What language(s) does your child speak? (Check all that apply)
Would you like to complete an ASQ? The ASQ is a developmental screening about the five areas of development. It's a simple questionnaire that allows you to see where your child is at in his/her development. *
Select YES to give permission to have photos and/or videos taken of you, your child(ren), or your family for our program promotion and social media pages.
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Disclaimer: All the information in this form will be uploaded to our database. *
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