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21-22 Early Childhood Registration Interest
Please complete the following survey for potential candidates/anyone who is interested in registering for the Lincoln County Early Childhood program.
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Child's Name:
Your answer
Child's Date of Birth:
MM
/
DD
/
YYYY
Child's Age:
Choose
0-12 months
1
2
3
4
School District in which you reside:
Choose
Crab Orchard
Highland
Hustonville
Stanford
Waynesburg
Parent/Guardian Name:
Your answer
Best phone number to reach you:
Your answer
Additional phone number:
Your answer
Do you suspect that your child has any developmental concerns such as speech, physical impairments, disabilities or delays?
Yes
No
Not sure
Other:
Clear selection
Additional notes/comments:
Your answer
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