Birth to Five Early Childhood Program 2021-2022
Please complete this form to register.  
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Email *
Today's Date *
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Parent (Caregiver) Full Name(s) *
Relationship to Child/Children *
Full Name(s) of Child(ren) & Date(s) of Birth *
Street Address *
City and Zip Code *
Phone *
Does this phone accept text messages? *
Email *
Any other information about your family you would like to share:
Are there any community resources, child development or parenting topics you would like more information about?
Demographic Information
The following questions are asked for reporting purposes only. Our free program is supported by grants that require us to report demographic information about the community we serve.  Your responses help us maintain our commitment to providing accessible programs. However, you are not required to share this information.
Race and/or Ethnicity
Primary language spoken in the home:
Does your family use (or qualify for) free or reduced lunch?
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How did you hear of our program?
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If other, please tell us:
A copy of your responses will be emailed to the address you provided.
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