Watertown Family Center Participant Information Form
Thank you for taking the time to complete this information. We use this information to help us plan services to meet the needs of the families we serve, and to tell our funders about who participates in our programming. Please fill out completely and release forms. Thank You!
Date: *
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Name (first and last and spouse/partner): *
Phone Number: *
Address: *
Current Zip Code *
Email Address: *
What Social Media do you use? *
Required
Names and Ages (Date of Birth) of all Children in House: *
Is your child in 4K? *
Required
Your Date of birth: *
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Sex: *
My race/ethnicity is (check all that apply): *
Required
Primary language spoken at home: *
I am a person with a disability: *
Marital status: *
Number of children living in my household: *
Number of children living in my household with a disability: *
Age of your child/children (please list all): *
My relationship to the children in my household is (check all that apply): *
Required
Are you pregnant? *
My annual household income is: *
My spouse / partner employment status is (check all that apply): *
Required
Veteran/military status (does your household include individuals who are serving or formerly served in the US armed forces)? *
My spouse / partner education level is: *
Are you currently enrolled in any other programs? *
Current zip code: *
Name of primary care provider: *
Do you have concerns about losing your housing within the next three months? (check all that apply): *
Required
How did you hear about this program? (check all that apply): *
Required
Have you ever attended Watertown Family Center program before? *
Have you ever attended Triple P class before? *
liability Release: It is understood that the Watertown Family Center, or their employees will not be held liable should accident/injury or illness occur while participating in Family Center programs at the Center or other locations. Parent/Guardian are responsible to supervise their own child(ren). Every effort will be made to provide a safe supervised environment for young children. *
PHOTO RELEASE: I give my permission for my child(ren)/myself to be photographed while attending activities sponsored by the Watertown Family Center. I understand these photos can be used for publicity purposes. *
GUARDIAN LIABILITY WAIVER : I give my permission for my child(ren)/to attend the Watertown Family Center with my child care provider, family member or friend.myself to be photographed while attending activities sponsored by the Watertown Family Center. I understand these photos can be used for publicity purposes. *
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