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SDOC 4K Registration
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Child's Last Name
Your answer
Child's First Name
Your answer
Child's Middle Name
Your answer
Child's Date of Birth
MM
/
DD
/
YYYY
Gender
Race
Child's Home Language
If you chose other, what is the child's home language?
Your answer
Has your child ever received early intervention services?
Child's Pediatrician/Family Doctor
Your answer
Medicaid
If yes, please bring your child's medicaid card to your appointment. If not, parent/guardian will need to bring proof of income (W2/current pay stub).
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