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Playgroup Registration Form 2018-2019

Parent/Guardian Information

Parent/Guardian Name: _____________________________________     Gender: M/F Date of Birth: ______________

Address: _________________________________________________________ East Hartford, CT  __06118  __06108                                                                              

Home Phone: ___________________ Cell:__________________  Email:___________________________________

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  

Parent’s primary language: ____________________

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      

Do the children have foster parents? __Yes   __No            

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

Are you interested in our playgroup? __Yes   __No     Preferred Day_________________________


Child 1 Information

Child’s Name                Date of Birth     Gender            Insured                 Immunized          

           

_______________________     ___/ ___/____       M/F                   Yes/No                   Yes/No            

 

Low birth weight? __Yes  __No             Premature? __Yes   __No           Primary Language:________________________

 

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    

 

Child 2 Information

Child’s Name                Date of Birth     Gender            Insured                 Immunized          

           

_______________________     ___/ ___/____       M/F                   Yes/No                   Yes/No            

 

Low birth weight? __Yes  __No             Premature? __Yes   __No           Primary Language:________________________

 

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)                       


  • 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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