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Playgroup Registration Form 2017-2018

Parent/Guardian Information:

 Parent/Guardian Name:____________________________   Gender: M/ F    Date of Birth:_______________

 Address: __________________________________________________ East Hartford, CT __06118 __06108                                                                         

 Home Phone: ________________  Cell: ___________________   Email: __________________________

 Parent’s Primary Language: ______________________    Do the children have foster parents? __Yes   __No

Parent’s Race: __American Indian or Alaska Native     __Asian     __Black or African American

                       __Pacific Islander      __White

 Parent’s Ethnicity: __Hispanic or Latino   __Not Hispanic or Latino  

Have you been unable to find work? __Yes   __No

Have you completed high school? __Yes   __No               Do you have a GED? __Yes   __No  

Are you currently receiving any public benefits? __Yes   __No      

Is either parent in active duty in the military? __Yes   __No      

Are you interested in our Parents as Teachers Home Visiting Program? __Yes   __No    

Child’s Information:

 Child’s Name:_______________________________________________ Date of Birth:_______________    

 Gender:   M   /    F                Insured:     Y   /     N                 Immunized:         Y    /  N      

 Primary Language:______________________________________________

  Low birth weight? Y   /     N           Premature? Y     /   N                    B-3 Services     Y     /     N                        

Child’s Race:    __American Indian or Alaska Native   __Asian       __Black or African American

__Pacific Islander       __White

 Child’s Ethnicity:     __Hispanic or Latino     __ Not Hispanic or Latino

 Restrictions: Food / Allergies / Health / Other: ___________________________________________

 I give the FRC permission to use, at its discretion, any photos or videos taken while in programs. Yes   No

 I hereby relieve the East Hartford Board of Education of liability resulting from personal injuries arising from participation in this program.

___________________________________________                   ____________________                         

(Signature)                                                                                                   (Date)  

Office Use Only        

 PAT Family ______             B-3______                                 Playgroup Day_______________              

Immunizations Received_______        ASQ Completed____________                                        

  • Hartford Courant Top Work Places 2011 Award Ribbon
  • Hartford Courant Top Work Places 2012 Award Ribbon
  • Hartford Courant Top Work Places 2013 Award Ribbon
  • Hartford Courant Top Work Places 2016 Award Ribbon
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