Watertown Family Connections                                      Family Participant Information Form

Each program year we ask families participating in our programs to fill out this form. All information that we receive is kept confidential and not given away! All of WFC’s programs are FREE and is made possible by grants, donations, fundraising and community donations.  

Please note that nearly 60% of the funding is from grants. Our funders require us to maintain statistics.  All information remains confidential, no names are used, and information used is just for grant writing.  

Thank you for taking the time to fill this out!

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 Date: *
Section 1.
About You!
Your Name (First & Last): *
Sex: *
Your Date of birth: *
Phone Number: *
Address: *
Current Zip Code *
Email Address:  *
Preferred Method of Contact: *
Are you:  (Please check all that apply) *
What is your education level? *
Marital status: *
Section 2.
About Your Partner
Name (first and last): 
If no partner, please enter NA
Is your partner/spouse:  (Please check all that apply) *
What is your partner's education level? *
Section 3.
My annual combined household income is: *
Veteran/military status (does your household include individuals who are serving or formerly served in the US armed forces)? *
My race/ethnicity is (check all that apply): *
Please tell us about all of your children (Name, Age, and Gender of your child/ren): *
My child(ren)'s race/ethnicity is (check all that apply): *
My relationship to the children in my household is (check all that apply): *
Total Number of People Living in Your Household (including you):  *
Number of Female Children living in household (please enter number)  *
Number of Male Children living in household (please enter number)  *
Do you have a child in 4K? *
If yes, which school do they attend? If no, please enter N/A. *
Are all your school-aged children enrolled in the current school year? *
Do any of your children have an IEP with the school district? If yes, please enter their name and which school they attend. If no, please enter N/A *
Primary language spoken at home: *
Section 4.
Almost Done!
When do you take your child to the doctor? *
Are your child's vaccinations up to date for their age? *
Does everyone in your family have health insurance? *
How did you hear about Watertown Family Connections? *
Are you pregnant? *
If yes, when are you due?  If no, please write NA. *
Do you have quality childcare, if needed? *
Are you able to access enough food to feed yourself and your family? *
Are you generally able to get to where you need to using a personal vehicle or public transportation? *
Do you have concerns about losing your housing within the next three months? (check all that apply): *
Total number of adults in household who are disabled  *
Number of children living in my household with a disability: *
Are you interested in learning about our programs? *
If yes, what programs do you want more information on? *
What social media do you use? *
Liability Release:  It is understood that the Watertown Family Connections, or their employees will not be held liable should accident/injury or illness occur while participating in watertown Family Connections 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 Connections.  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 Connections with my childcare provider, family member or friend while attending activities sponsored by Watertown Family Connections.   *
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