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Application for ECHN Family Development Center
All programs through ECHN’s Family Development Center are voluntary and free of charge. Our dedicated staff will assist you in finding the appropriate program that best meets your needs.
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* Indicates required question
Email
*
Your email
Todays Date
*
MM
/
DD
/
YYYY
Are you...?
*
the parent
Referring a parent
If referring, agency contact information:
Your answer
Where did you hear about our program?
*
WIC
Library
Another enrolled family
Pediatrician
Case Worker
Therapist
Other:
Other:
Child's first and last
*
Your answer
Child's date of birth
*
MM
/
DD
/
YYYY
Child's Gender
*
Male
Female
Prefer not to say
Other:
Race:
*
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Multi-racial
Prefer not to report
Other:
Hispanic or Latino?
*
Yes
No
Child's home address
Your answer
Primary language spoken in home
*
Your answer
Parent/Guardian First and Last Name:
*
Your answer
Parent/Guardian date of birth
*
MM
/
DD
/
YYYY
Relationship to child
*
Mother
Father
Guardian
Foster
Other
Other:
Contact Phone Number:
*
Your answer
Check all that apply for your family:
*
Single parent/guardian
Referred by DCF
Teen parent
Child has limited English proficiency
I am concerned that my child may be developmentally delayed
I am interested in learning parenting tips
I am interested in playgroups
Other:
Required
In the past 12 months has your family received:
*
SSI
TANF/Cash Assistance
SNAP/Foodstamps
WIC
Medicaid/Husky
Section 8/Public Housing
None of the above
Other:
Which best describes the living arrangements of your family?
*
Stable housing
Sharing the housing of others due to loss of housing, economic hardship or similar reason
In shelter or transitional housing
Unsheltered
Number of people in your family
*
Your answer
Income sources for your family
*
Wages
Child support
Worker's Compensation
Unemployment
Pension/Retirement
Social Security
SSI
TANF
Other:
Estimated total yearly income
*
Less than $10,000
$10,000-$19,999
$20,000-$29,999
$30,000-$39,999
$40,000-$49,999
$50,000-$59,999
Greater than $60,000
I would like to apply for an additional child who is under three:
*
Yes
No
Send me a copy of my responses.
Submit
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