2017-2018 Cass County Early Childhood Education Intake Form
What Early Childhood Program(s) have your child been enrolled in?
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How did you hear about Early Childhood Programming in your community?
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Child Last Name
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Child First Name
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Gender
Date of Birth
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Parent/Guardian Names
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Street Address
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City
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School District
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Phone Number
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Alternate Phone Number
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Email Address
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Is there an IEP/IFSP currently in place for this child?
What concerns do you have about your child's speech, language or development?
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Gross Income (All Sources of income) GSRP and Head Start Applicants only
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Number of Family in Home
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Check all that apply
Language
Notes/Special Instructions
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