Family Involvement Center Registration Form

1. Who is completing this registration?
¿Quién está completando este registro? *This question is required.

2. How did you find out about the Family Involvement Center? ¿Cómo se enteró del Centro de participación familiar? *This question is required.

Please enter an 'other' value for this selection.

3. Which location will you be visiting? Que sitio planeas visitar?
*This question is required.

4. Child's/Children's Name - Nombre de niño(a) *This question is required.

5.
Child's/Children's Date of Birth/ Ages- Fecha de Nacimiento del niño(a)/y siglos *This question is required.

6. How many children live in the home? ¿Cuántos niños viven en el hogar? *This question is required.

7. # of children being registering? - Número de niños registrando? *This question is required.

8. Please confirm that the child(ren) you are referring is/are in compliance with vaccination requirements.
Por favor confirme que el nino(a) cumple con los requisitos de vacunacion.

****COMMUNITY MEMBERS PLEASE BRING IN A COPY OF YOUR CHILD'S IMMUNIZATION RECORDS OR IMMUNIZATION EXEMPTIONS ON YOUR 1ST VISIT.****
****MIEMBROS DE LA COMUNIDAD POR FAVOR TRAIGA UNA COPIA DE LOS REGISTROS DE INMUNIZACIÓN DE SU HIJO O EXENCIONES DE VACUNAS EN SU PRIMERA VISITA****

*This question is required.

9. How many total people live in the home? ¿Cuántas personas en total viven en el hogar?

11. Languages spoken at home? ¿Idiomas hablados en casa? *This question is required.

12. Parent/Caregiver Name / Nombre de los Padres/Cuidador(a) ?
*This question is required.

13. Telephone Number - Número de Teléfono *This question is required.

14. Mailing Address - Direccion *This question is required.

15. E-mail Address - Correo Electrónico *This question is required.

16. Is your family receiving services from MCITP? - Su familia recibe servicios de MCITP? *This question is required.

17. If Applicable-MCITP ( Montgomery County Infant and Toddler Program )Provider's Name? / Nombre de la Provedora?

18. Provider's Site? - Su Centro?

19. Please tell us which date you plan on coming for your first visit? - Por favor anotar la fecha que planifica du primer visita?

*Reminder: MCITP Providers MUST attend first visit with families.
* Recordatorio: los proveedores de MCITP DEBEN asistir a la primera visita con las familias.

20. What day(s) of the week would you like to come consistently?

NO MORE THAN 2 DAYS *This question is required.

Mondays: (9:30 am - 1:30 pm)
Tuesdays: (9:30 am - 1:30 pm)
Wednesdays: (9:30 am - 1:30 pm)
Thursdays: (9:30 am - 1:30 pm)
Fridays: (9:30 am - 1:30 pm)

21. Family Will Attend/ Vamos a Participar...

22. Additional Comments/Comentarios adicionales.

MCITP Providers & Care Givers(Parent/Guardians):
Please share your goals for you and your child in attending the Family Involvement Center

Proveedores de MCITP y cuidadores (padres / tutores):
Comparta sus objetivos para usted y su hijo al asistir al Centro de Participación Familiar

*This question is required.

Family Involvement Center Registration Form

Registration - Registracion