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Child Enrollment Form
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CHILD
Name
*
First
Last
Date of Birth
*
MM
1
2
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5
6
7
8
9
10
11
12
/
DD
1
2
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5
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13
14
15
16
17
18
19
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21
22
23
24
25
26
27
28
29
30
31
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YYYY
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Gender
Race / Ethnicity
American Indian or Alaskan Native Choice
Asian
Black or African American
White, non hispanic
Native Hawaiian or Other Pacific Islander
Hispanic, Latino or Spanish origin
Other
Prefer not to say
Date of Placement:
MM
1
2
3
4
5
6
7
8
9
10
11
12
/
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
YYYY
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
CPS INVOLVEMENT
Is the child currently involved with CPS?
*
Yes
No
Dependency Status:
*
Court Dependent
Not-Court Dependent
Unknown
Carrying Case Worker:
Case Worker Phone
Case Worker Email
*
County
*
Current zip code
*
Guardian's Name
*
Phone
Email
*
CURRENT LEGAL/ GUARDIANSHIP STATUS
*
Adoption by Caregiver
Formal Foster Placement
Undetermined
Informal Supervision Placement
Informal Arrangement
Juvenile Probation (Ward)
Legal Guardian no KinGap (Non-Dependent Guardianship)
Other:
Legal Guardian w/ KinGap (Dependent Guardianship)
N/A
PERMANENCY GOAL
Adoption
Guardianship
Independent Living
No goal established
Reunification with Parent
Other:
CHILD’S HEALTH INFORMATION
Does the child have health insurance?
*
Yes
No
Uknown
If yes, (Insurer/Type):
*
Please provide ID and Group Number:
Does the child currently suffer from health problems?
Yes
No
Unknown
Declined to State
If yes, describe:
In case of Emergency please list names and phone numbers of two other contacts:
Does the child have any therapeutic services in place?
Yes
No
Unknown
Declined to State
If Yes:
Name of provider:
How long has this child been receiving services?
CHILD’S AREA OF STRENGTHS
Please list at least 3:
CONCERNS REGARDING CHILD’S BEHAVIOR
Yes
No
If yes, please describe:
*
EDUCATION
Is the child currently attending school?
Yes
No
Not School Age
Does the child have any of the following?
IEP
504
N/A
School Name:
Grade Level:
School District:
EDUCATIONAL STRENGTHS
EDUCATIONAL CONCERNS (If Any)
EXTRACURRICULAR/ ENRICHMENT ACTIVITIES
Please choose activities that your child maybe interested in participating
*
Basketball
Football
Dance
Musical Instrument Lessons
Baseball
Swimming
Drama/Theatre
Gymnastics
Softball
Martial Arts
Tutoring
Soccer
Arts/Crafts
Other
Please list other activities here:
FORMS/ REQUIREMENTS TO PARTICIPATE
How much time are you able to commit per week for your child to participate in the activity of their choice?
1-2 hours/ week
3-4 hours/ week
5-6 hours/ week
6 of more
None
Can you provide transportation?
YES
NO
What additional resources would be helpful for your family to ensure your child could participate in the activity of their choice?
Do you have an original birth certificate you can provide?
YES
NO
Can you provide a recent photo (face only) with no sunglasses or hat?
YES
NO
Caregiver's Printed Name
Caregiver's Signature
Clear Signature
Date
Submit
