Child's Legal Name (Last):

Child's Legal Name (First):

Child's Sex:

Child's Date of Birth:

Language Spoken in Home:

Child's Legal Guardian:

Legal Guardian's Name:

Mother Father Grandparent Other

Living/Mailing Address:

City:

State:

Zip:

County:

Preferred Method of Contact:

Home Phone Cell Phone Text Message Email Other

if other

TV Radio Flyer Word of Mouth Other

if other