First Steps Application Form First Steps Intake Form Parent/Guardian Information: Parent/Guardian Full Name * Relationship to Child * Parent/Guardian Date of Birth * Mailing Address * Mailing Address Mailing Address Mailing Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Home Phone * Cell Phone (if different from home phone) Work Phone Email * Preferred Method of Contact * Highest Level of Education Completed * No schooling completed Elementary school to 8th grade Some high school, no diploma High school graduate, diploma or the equivalent (for example: GED) Some college credit, no degree Trade/techincal/vocational training Associate degree Bachelor's degree Master's degree Professional degree Doctorate degree Employer * Parent/Guardian Status * Single Parent Two parent Non-parent Foster parent Grandparent OtherOther Family Services Received (check all that apply) * SSI TANIF Section 8 Medicaid WIC Food Stamps Kid CHIP OtherOther None of the above Do you currently have a libray card? * Yes No Do you have reliable transportation? * Yes No Child Information How many children are you filling out an intake form for? * 12345 Child's first name * Child's last name * Child's date of birth * Child's gender * Is child currently enrolled in any of the following? * Stride Head Start Parents as Teachers LCSD#1 Pre-K program Other preschool or daycare program None of the above OtherOther Does child have any special needs or disabilities that may require special accomodations? 0 of 500 max words Is child currently diagnosed with an IFSP or IEP? * Yes No Not sure Do you have any concerns about child's development? 0 of 500 max words Second child's first name * Second child's last name * Second child's date of birth * Second child's gender * Is child currently enrolled in any of the following? * Stride Head Start Parents as Teachers LCSD#1 Pre-K program Other preschool or daycare program None of the above OtherOther Does child have any special needs or disabilities that may require special accomodations? 0 of 500 max words Is child currently diagnosed with an IFSP or IEP? * Yes No Not sure Do you have any concerns about child's development? 0 of 500 max words Third child's first name * Third child's last name * Third child's date of birth * Third child's gender * Is child currently enrolled in any of the following? * Stride Head Start Parents as Teachers LCSD#1 Pre-K program Other preschool or daycare program None of the above OtherOther Does child have any special needs or disabilities that may require special accomodations? 0 of 500 max words Is child currently diagnosed with an IFSP or IEP? * Yes No Not sure Do you have any concerns about child's development? 0 of 500 max words Fourth child's first name * Fourth child's last name * Fourth child's date of birth * Fourth child's gender * Is child currently enrolled in any of the following? * Stride Head Start Parents as Teachers LCSD#1 Pre-K program Other preschool or daycare program None of the above OtherOther Does child have any special needs or disabilities that may require special accomodations? 0 of 500 max words Is child currently diagnosed with an IFSP or IEP? * Yes No Not sure Do you have any concerns about child's development? 0 of 500 max words Fifth child's first name * Fifth child's last name * Fifth child's date of birth * Fifth child's gender * Is child currently enrolled in any of the following? * Stride Head Start Parents as Teachers LCSD#1 Pre-K program Other preschool or daycare program None of the above OtherOther Does child have any special needs or disabilities that may require special accomodations? 0 of 500 max words Is child currently diagnosed with an IFSP or IEP? * Yes No Not sure Do you have any concerns about child's development? 0 of 500 max words If you are human, leave this field blank. Submit Start Over Δ
