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: