# 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: ____