Child's Legal Name (Last):
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Child's Legal Name (First):
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Sex:
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Date of Birth:
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Language Spoken in Home:
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Secondary Language:
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Legal Guardian:
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if other
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Living/Mailing Address:
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City:
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State:
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Zip:
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County:
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Mother's Name:
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Mother's Address:
(if different from above)
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Father's Name:
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Father's Address:
(if different from above)
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Home Phone:
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Cell Phone:
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Email
Address:
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Secondary Contact:
(Phone Number and Relationship)
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Preferred Method of Contact:
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if other
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| How did you hear about Head Start/Early Head Start? |
if other |
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