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 Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 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? * 1 2 3 4 5 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
