Play and Learn Group Registration Form

Parent/Legal Guardian 1 Information

First and Last Name First and Last Name

Street Address Be sure to add the house, building, or apartment number.

City

Zip Code

Phone Number

Email Address

Parent/Legal Guardian 2 Information

First and Last Name

Street Address Be sure to include the house, building, or apartment number.

City

Zip Code

School District Pick the District where you reside.

Email Address

CHILD 1 Information (under 5 years of age)

Child 1 First and Last Name

Child 1 Date of Birth

Child 1 Race (check all that apply) Demographic data is based upon collected by grant funders American Indian/Alaska Native Asian American Black/African American Hispanic/Latino Native Hawaiian/Pacific Islander White Other

Child 1 Gender at Birth Female Male

Who does Child 1 reside with?

If Child 1 CURRENTLY has an Early On or GPGS Home Visitor, please list their name.

CHILD 2 Information (under 5 years of age)

Child 2 First and Last Name

Child 2 Date of Birth

Child 2 Race (select all that apply) American Indian/Alaska Native Asian American Black/African American Hispanic/Latino Native Hawaiian/Pacific Islander White Other

Child 2 Gender Assigned at Birth Female Male

Who does the Child 2 reside with?

If Child 2 CURRENTLY has an Early On or GPGS Home Visitor, please list their name.

CHILD 3 Information (under 5 years of age)

Child 3 First and Last Name

Child 3 Date of Birth

Child 3 Race (check all that apply) American Indian/Alaskan Native Asian American Black/African American Hispanic/Latino Native Hawaiian/Pacific Islander White Other

Child 3 Gender Assigned at Birth Female Male

Who does the child reside with?

If Child 3 CURRENTLY has an Early On or GPGS Home Visitor, please list their name.

Family Information

Primary Language Spoken in the Household

Does anyone in the family have a disability or delay? If yes, please explain. Is there additional information you would like us to know about your child(ren).

Where did you hear about our program? Family Friend Library Event (Zoo Days, etc.) Website/Social Media Childcare Physician Preschool/GSRP Head Start WIC Ingham County Heath Dept. Other