Watertown Family Connections                                      Participant Information, Liability & Photo Release Form

  This form must be completed and signed by the participant or participant's parent/legal guardian.

  •   We ask all families participating in our programs to complete this form once per program year. We use this information to plan our programs around the demographics and unique needs of the families we serve. 
  •   All of WFC’s programs are FREE and are made possible by grants, donations, fundraising and community donations. 
  •   Nearly 60% of the funding for our programs comes from grants. Our funders require us to maintain statistics, and provide demographic information about the families we serve. This form must be completed and signed in order to participate in our programs so that we may best serve you and your family.

  Thank you!

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Today's Date: *
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Section 1.
Participant/Parent/Legal Guardian Information
Your Name (First & Last): *
Your Date of Birth: *
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Your Sex/Gender: *
Your Pronouns:
Your Primary Phone Number: *
Your Address: (Street, City, State) *
Current Zip Code *
Your Email Address:  *
Preferred Method of Contact: *
Your Primary Language: *
Your Race/Ethnicity: (Check all that apply) *
Required
Your Employment Status: (Please check all that apply) *
Required
Your Education Level:  *
Marital status: *
Are you pregnant? *
If yes, when are you due?  If no, please write NA. *
Section 2.
Secondary Caregiver/Partner/Spouse Information- If none, please enter NA (not applicable) in all fields.
Secondary Caregiver/Partner/Spouse Name (first and last): *
Secondary Caregiver Pronouns
Secondary Caregiver Phone Number: *
Secondary Caregiver Address: (Street, City, State)
*if address is same as Participant's, please enter "Same"
 *
Secondary Caregiver Primary Language *
Secondary Caregiver Race/Ethnicity: (Please check all that apply)
Secondary Caregiver Employment Status:  (Please check all that apply) *
Required
Secondary Caregiver Education Level: *
Section 3.
Demographics/Household Information
Annual combined household income: *
Total Number of People Living in Your Household (including you):  *
Veteran/military status (does your household include individuals who are serving or formerly served in the US armed forces)? *
Please list the Name, Age, and Gender of all children in your household:  *
Child(ren)'s Primary Address: *
Child(ren)'s Primary Language:
Clear selection
Child(ren)'s race/ethnicity: (Check all that apply) *
Required
Your relationship to the child(ren) in the household: (Check all that apply) *
Required
Number of Female Children living in household (please enter number)  *
Number of Male Children living in household (please enter number)  *
Have any of the children in your household had a developmental screening? *
If yes, where? (If no, please enter NA/Not Applicable)
Do you have a child in 4K? *
Required
If yes, which school do they attend? If no, please enter N/A. *
Are all your school-aged children enrolled in the current school year? *
Required
Do any of your children have an IEP with the school district? If yes, please enter their name and which school they attend. If no, please enter N/A *
Primary language spoken at home: *
When do you take your child(ren) to the doctor? *
Required
Are your child(ren)'s vaccinations up to date for their age? *
Section 4.
Resource Network Inquiry
Does everyone in your family have health insurance? *
Required
Do you have quality childcare, if needed? *
Required
Are you able to access enough food to feed yourself and your family? *
Required
Are you generally able to get to where you need to using a personal vehicle or public transportation? *
Required
Do you have concerns about losing your housing within the next three months? (check all that apply): *
Required
Total number of adults in household who are disabled  *
Number of children in household who are disabled: *
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