Client Information Sheet

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Your Name *

Your Phone *

Your Email *

Your Address *

Please include City, State, and Zip Code

Date of Birth *

What is your date of birth?

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Race/Ethnicity *

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White/Caucasian

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American Indian or Alaska Native

Other

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Household Annual Income *

Less Than $20,000

$20,000 to $34,999

$35,000 to $49,999

Greater than $50,000

Do you or anyone in your household smoke? *

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Yes

Required

If you are pregnant now, what is your due date?

YYYY

How many people live in your household? *

Names and Birthdates of all children under 8 years old in your house: *

REQUIRED: Please put N/A if this does not apply

Does anyone else in your household earn vouchers? *

Yes

Required

Little Lambs Liability: I will not hold Little Lambs of Evansville, Inc., its staff or volunteers, or anyone who may be associated with Little Lambs of Evansville, Inc. responsible for any injury or death that may occur as a result of using any product received from Little Lambs of Evansville, Inc. or from education received at Little Lambs of Evansville, Inc. *

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