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