Todays' date:
    Childs' legal first name:
    Childs' legal middle name:
    Childs' legal last name:
    Childs' date of birth:
    Childs' gender at birth:
    Please upload proof of age:
    Custody:

    Court orders:

    Childs' home address:
    Language spoken at home:
    Which Strong Start program will you attend most often:
    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:

    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:
    Alternate Emergency Contact Name:
    Alternate Emergency Contact Telephone:
    Can this person pick-up the child: