Birth to Five Early Childhood Program 2019-20
Please complete this form to register. Program staff will contact you to confirm your registration and start date.
Today's Date *
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Will your family attend: *
Name of Child/Children Participating in the Program & Date of Birth *
Your answer
Parent (Caregiver) Name *
Your answer
Relationship to Child/Children *
Your answer
Street Address *
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City and Zip Code *
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Phone *
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Email *
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What is your preferred method to contact you? *
Ethnicity:
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Primary language spoken in the home: *
Your answer
Does your family qualify for free or reduced lunch? *
Does your child have any special dietary needs, allergies, or health issues? *
Your answer
Are there any early childhood development or parenting topics you would like more information about?
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Are there any community resources you would like more information about?
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Any other information you need or would like to share:
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How did you hear of our program? *
If other, please tell us:
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