Locations
Contact Us
Search Icon
Events
Donate
Home
Services
Community Services
Employment & Training
Food Program
Housing
Pardon Project
Volunteer Income Tax Assistance - VITA
Early Childhood Education
Family Center
Transportation
Weatherization
Who We Are
Company Page
Careers
Organization Documents
Employee Access
Staff Email
Intranet
FSA Claim Login
Optum Bank Login
Time Management
Disclaimer
Locations
Menu
Close
Home
Services
Community Services
Employment & Training
Food Program
Housing
Pardon Project
Volunteer Income Tax Assistance - VITA
Early Childhood Education
Family Center
Transportation
Weatherization
Who We Are
Company Page
Careers
Organization Documents
Employee Access
Staff Email
Intranet
FSA Claim Login
Optum Bank Login
Time Management
Disclaimer
Locations
Locations
Contact Us
Search Icon
Events
Donate
Please complete all questions below.
Child's First Name: (Mandatory Field):
Child's Last Name: (Mandatory Field):
Child's Date of Birth: (Mandatory Field):
Doctor/Specialist:
Therapist:
IU-O8:
Early Intervention:
Easter Seals:
TSS/BSC:
Was this a "high risk" pregnancy or any problems at birth? (mom or child):
If "high risk", please explain::
Was the child premature?:
Did the child have a low birth weight?:
Are there documented postpartum/depression issues?:
Was the child referred to our program?:
If referred, by whom?:
Is the child currently enrolled in Early Head Start?:
Is a natural parent in jail/prison?:
Do you have 3 or more children under the age of 5?:
Receiving services from CYS?:
Substance/Drug Abuse:
IEP/IFSP:
Domestic Violence:
Loss of Employment:
Bankruptcy:
Death of family member in household:
Major illness or accident:
Email Address: (Mandatory Field):
Chat with us
, powered by
LiveChat