Demographic Information Sheet

Today's date: ____
Child's name (first/middle/last): ____
Child's date of birth (MM/ DD/YYYY): ____ / ____ / ____
If child was born premature, # of weeks premature: _________________________________
Child’s gender: Male O O Female
Child's race/ethnicity: ____
Child's birth weight (pounds/ounces): ____
Parent/primary caregiver’s name (first/middle/last): __________________________________
Relationship to child: ____
Street address: ____
City: ____
State/province: ____ ZIP/postal code: ____
Home telephone: ____ Work telephone: ____
Cell/other telephone: ____
E-mail address: ____
Child's primary language: ____
Language(s) spoken in the home: ____

Child's primary care physician

Child's primary care physician: ____
Clinic/location/practice name: ____
Clinic/practice mailing address: ____
City: ____
State/province: ____ ZIP/postal code: ____
Telephone: ____ Fax: ____
E-mail address: ____
Please list any medical conditions that your child has: ____
Please list any other agencies that are involved with your child/ family: ____

Program Information

Child ID #: ____
Date of admission to program: ____
Child’s adjusted age in months and days (if applicable): ______________________________
Program ID #: ____
Program Name: ____