Birth to Five Early Childhood Program - Fall 2020
Please complete this form to register.  Program staff will contact you to confirm your registration and start date.
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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:
Program Participation
We understand that you may not be able to regularly participate in all parts of the program. If you are unable to attend or think it will be difficult to regularly attend one or more of our program offerings, please indicate below.
Our family CANNOT participate in (please check all that apply): *
Required
Comments on participation
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:
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