Ignite in every child a passion for a lifetime of learning
Child’s Full Name
Child’s Date of Birth
Child’s Current Age
Child’s Gender FemaleMale
Is the child potty-trained? YesNo
Does the child receive Special Education Services (IEP)? YesNo
Does the child receive Speech Services (IEP)? YesNo
Does the child receive Early Intervention Services (IFSP)? YesNo
Does the child have a suspected disability? YesNo
If Yes, what is the suspected disability?
In what kind of setting does your child currently receive care? No previous child careIn-home careCare at a center/facility
Guardian Name
Your email
Guardian’s Relationship to Child
Number in Household
Primary Household Language EnglishSpanishVietnameseMandarinOther
Guardian Phone Number
Guardian E-mail Address
Does anyone in the household currently receive SNAP or CCAP assistance? YesNo
