Todays' date: Childs' legal first name: Childs' legal middle name: Childs' legal last name: Childs' date of birth: Childs' gender at birth: FemaleMaleNon-BinaryPrefer not to say Please upload proof of age: Custody: Both ParentsOthers; describe below Court orders: NoYes; describe below Childs' home address: Language spoken at home: Which Strong Start program will you attend most often: Agnes L. MathersPort Clements ElementarySk'aadgaa Naay ElementaryTahayghen Elementary Does the child have a life threatening illness?: Does the child have a non-life threatening illness?: Parent / Guardian Information Parent / Guardian name: Parent / Guardian type: MotherFatherOther Guardians' home address: Primary phone number: Alternate phone number: Email address: Place of Employment: Alternate Emergency Contact (custodial parents will always been contacted first) Emergency Contact Name: Emergency Contact Telephone: Can this person pick-up the child: YesNo Alternate Emergency Contact Name: Alternate Emergency Contact Telephone: Can this person pick-up the child: YesNo