Cold Springs Early Childhood Center Family Assistance Request Form  
Occasionally, families find themselves in need of resources from school and the community.  It is my goal to assist our families in accessing these resources while maintaining complete confidentiality.  If you are a family who anticipates needing assistance of any kind this year, please complete this survey. You may contact me at any time during the school year as needs arise. We ask that families complete a new form each school year as situations can change.  

Please understand we cannot guarantee that all needs will be met, but we will do our very best!

Andi Dahlberg, CPIS
Cold Springs ECC
856-456-7000 x-2141

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Parent Email Address *
Parent Name(s)
*
Parent Cell Phone Number
*
Please provide information for all children in the household
(including children not yet in school or those attending other schools) to help us better assist your family. Please include each child's name, grade and school. For Children not yet in school please include their age.
For example: John Doe, 4th grade S.A Elementary. ; Jane Doe, 2 years old ; Jim Doe, 5th grade S.A Elementary.
Child's Name(s), Grade/School*
*
Do you require an interpreter?*
*
If yes, please indicate what language:
Your answer

*
Resources Available
This list gives examples of various forms of community resources that are typically available. Please contact us for any additional needs that are not listed. Our goal is to help families meet their needs by referring them to existing resources in the community. We do so by maintaining an extensive list of these resources.  Select what you anticipate needing or what your current needs are and we will inform you as we learn of availability.

Remember this is for a need, not convenience.

Please understand that this is not a guarantee that the services can be provided. During the year, please let us know if your circumstances change and if you no longer need our assistance.

All information is strictly confidential.
Food Resources
Please check any item for which you would like more information
*
Required
Clothing
*
Required
Please provide the age, gender and specific sizes for each child in need of clothing and/or coats. For example, "My son is 3 and needs a size 4t coat, my daughter is 6 and needs size 7 pants and size 6 tops."

*
Medical and Dental Resources
*
Required
Additional Resources
*
Required
Would you like to schedule a meeting to discuss your situation? All discussions will remain confidential. If you choose "Yes" I will contact you to schedule a time.
*
Please include any additional information that may help us help you!
*
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