The Children's Council

Intake Form
2021-2022

Tell us about yourself:

Date of Birth
Relation to Child(ren)
Guardian Ethnicity
Expected Due Date

Tell us about your household:

Additional adults:
Date of Birth
Relation to Child(ren)
Ethnicity
Expected Due Date
+

Adult

Additional adults:
Date of Birth
Relation to Child(ren)
Ethnicity
Expected Due Date
+ -

Adult

Additional adults:
Date of Birth
Relation to Child(ren)
Ethnicity
Expected Due Date
+ -

Adult

Additional adults:
Date of Birth
Relation to Child(ren)
Ethnicity
Expected Due Date
+ -

Adult

Additional adults:
Date of Birth
Relation to Child(ren)
Ethnicity
Expected Due Date
+ -

Adult

Additional adults:
Date of Birth
Relation to Child(ren)
Ethnicity
Expected Due Date
+ -

Adult

Additional adults:
Date of Birth
Relation to Child(ren)
Ethnicity
Expected Due Date
+ -

Adult

Additional adults:
Date of Birth
Relation to Child(ren)
Ethnicity
Expected Due Date
+ -

Adult

Additional adults:
Date of Birth
Relation to Child(ren)
Ethnicity
Expected Due Date
+ -

Adult

Additional adults:
Date of Birth
Relation to Child(ren)
Ethnicity
Expected Due Date
+ -

Adult

Additional adults:
Date of Birth
Relation to Child(ren)
Ethnicity
Expected Due Date
+ -

Adult

Additional adults:
Date of Birth
Relation to Child(ren)
Ethnicity
Expected Due Date
+ -

Adult

Additional adults:
Date of Birth
Ethnicity
Expected Due Date
+ -

Adult

Additional adults:
Date of Birth
Relation to Child(ren)
Ethnicity
Expected Due Date
+ -

Adult

Additional adults:
Date of Birth
Relation to Child(ren)
Ethnicity
Expected Due Date
+ -

Adult

Additional adults:
Date of Birth
Relation to Child(ren)
Ethnicity
Expected Due Date
+ -

Adult

Additional adults:
Date of Birth
Relation to Child(ren)
Ethnicity
Expected Due Date
+ -

Adult

Additional adults:
Date of Birth
Relation to Child(ren)
Ethnicity
Expected Due Date
+ -

Adult

Additional adults:
Date of Birth
Relation to Child(ren)
Ethnicity
Expected Due Date
+ -

Adult

Additional adults:
Date of Birth
Relation to Child(ren)
Ethnicity
Expected Due Date
-

Adult

Children:
Date of Birth
Ethnicity
Will child be attending our childcare for classes/groups?
Expected Due Date
+

Child

Children:
Date of Birth
Ethnicity
Will child be attending our childcare for classes/groups?
Expected Due Date
+ -

Child

Children:
Date of Birth
Ethnicity
Will child be attending our childcare for classes/groups?
Expected Due Date
+ -

Child

Children:
Date of Birth
Ethnicity
Will child be attending our childcare for classes/groups?
Expected Due Date
+ -

Child

Children:
Date of Birth
Ethnicity
Will child be attending our childcare for classes/groups?
Expected Due Date
+ -

Child

Children:
Date of Birth
Ethnicity
Will child be attending our childcare for classes/groups?
Expected Due Date
+ -

Child

Children:
Date of Birth
Ethnicity
Will child be attending our childcare for classes/groups?
Expected Due Date
+ -

Child

Children:
Date of Birth
Ethnicity
Will child be attending our childcare for classes/groups?
Expected Due Date
+ -

Child

Children:
Date of Birth
Ethnicity
Will child be attending our childcare for classes/groups?
Expected Due Date
+ -

Child

Children:
Date of Birth
Ethnicity
Will child be attending our childcare for classes/groups?
Expected Due Date
+ -

Child

Children:
Date of Birth
Ethnicity
Will child be attending our childcare for classes/groups?
Expected Due Date
+ -

Child

Children:
Date of Birth
Ethnicity
Will child be attending our childcare for classes/groups?
Expected Due Date
+ -

Child

Children:
Date of Birth
Ethnicity
Will child be attending our childcare for classes/groups?
Expected Due Date
+ -

Child

Children:
Date of Birth
Ethnicity
Will child be attending our childcare for classes/groups?
Expected Due Date
+ -

Child

Children:
Date of Birth
Ethnicity
Will child be attending our childcare for classes/groups?
Expected Due Date
+ -

Child

Children:
Date of Birth
Ethnicity
Will child be attending our childcare for classes/groups?
Expected Due Date
+ -

Child

Children:
Date of Birth
Ethnicity
Will child be attending our childcare for classes/groups?
Expected Due Date
+ -

Child

Children:
Date of Birth
Ethnicity
Will child be attending our childcare for classes/groups?
Expected Due Date
+ -

Child

Children:
Date of Birth
Ethnicity
Will child be attending our childcare for classes/groups?
Expected Due Date
+ -

Child

Children:
Date of Birth
Ethnicity
Will child be attending our childcare for classes/groups?
Expected Due Date
-

Child

Address

State
County

Contact Information

Preferred Method of Contact
Emergency Contact:

About you:

Parent's highest level of education
Currently in school?

About your family:

Agency Relationship

All programs you have ever been part of: (please check all that apply)