FRC Registration (rev 20220311) FRC Registration 2022-2023 The Family Resource Center Play & Learn Group EnrollmentThis form is for the registration of the Family Resource Center Play & Learn Groups. Families must pre-register via Eventbrite. For questions about Play & Learn Groups please call 860-437-4550.Parent/Guardian InformationName* First Last Date of Birth* MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone* Medical & Dental Information Uninsured?* Yes No Immunized* Yes No Dental Checkup* Yes No Dental Care* Regularly NOT Regularly Medical Care* Dr. Office Minute Clinic Outpatient ER Community Health Other Race and EthnicityAre you Hispanic or Latino?* Yes No Ethnicity (check all that apply)* American Indian/Alaska Native Native Hawaiian/Pacific Islander Black/African American White Asian Add Second Parent/Guardian Information* Yes No Second Parent/Guardian InformationName* First Last Date of Birth* MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone* Medical & Dental Information Uninsured?* Yes No Immunized* Yes No Dental Checkup* Yes No Dental Care* Regularly NOT Regularly Medical Care* Dr. Office Minute Clinic Outpatient ER Community Health Other Race and EthnicityAre you Hispanic or Latino?* Yes No Ethnicity (check all that apply)* American Indian/Alaska Native Native Hawaiian/Pacific Islander Black/African American White Asian Child's Information Parents/Guardians list ALL children who will be attending program. Child (1) Name* First Last Child (1) Date of Birth* MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Child (1) Hispanic/Latino* Yes No Ethnicity (check all that apply)* American Indian/Alaska Native Native Hawaiian/Pacific Islander Black/African American White Asian Is there a 2nd child to register?* Yes No Child (2) Name* First Last Child (2) Date of Birth* MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Child (2) Hispanic/Latino* Yes No Ethnicity (check all that apply)* American Indian/Alaska Native Native Hawaiian/Pacific Islander Black/African American White Asian Is there a 3rd child to register?* Yes No Child (3) Name* First Last Child (3) Date of Birth* MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Child (3) Hispanic/Latino* Yes No Ethnicity (check all that apply)* American Indian/Alaska Native Native Hawaiian/Pacific Islander Black/African American White Asian Is there a 4th child to register?* Yes No Child (4) Name* First Last Child (4) Date of Birth* MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Child (4) Hispanic/Latino* Yes No Ethnicity (check all that apply)* American Indian/Alaska Native Native Hawaiian/Pacific Islander Black/African American White Asian Medical & Dental Information Uninsured* Yes No Immunized* Yes No Dental Checkup* Yes No Dental Care* Regularly Not Regularly Medical Care* Dr. Office Minute Clinic Outpatient ER Community Health Other Please indicate if you have any concerns about your child(ren) (i.e. allergies, fears, delays)Photo ReleaseI give permission for my child(ren) to be included in photographs, slides, and/or videos that may be taken while involved in playgroup activities which appear in any media coverage and social networking approved by Child & Family Agency.* Yes No Family Assessment Select Yes or NoChronic health problems, e.g., asthma, obesity* Yes No Chronic school or preschool attendance problems* Yes No Developmental delays* Yes No Disabilities* Yes No Frequently changed schools within short periods of time* Yes No Very low birth weight* Yes No Low birth weight* Yes No Premature birth* Yes No Reading or other academic challenges* Yes No Serious behavior concerns* Yes no Suspended or expelled from early care or early education* Yes No Serious oral health problems* Yes No Abuse or neglect* Yes No Chronic unemployment or underemployment* Yes No Death of parent or other family member* Yes No Divorce or estrangement of parent* Yes No Domestic violence* Yes No Involved with multiple health / social service agencies* Yes No Foster parents, court-appointed guardians* Yes No Grandparent / other relative is primary caregiver* Yes No High crime neighborhood* Yes No Homeless or numerous family relocations* Yes No Low educational attainment* Yes No Low income* Yes No Immigrant or refugee status* Yes No Multi-sibling family* Yes No Military family* Yes No Parent in active duty* Yes No Parent incarcerated* Yes No Parent with disabilities* Yes No Parent with chronic health problems* Yes No Parent with chemical dependencies* Yes No Single-parent household* Yes No Speakers of other languages (ELL)* Yes No Teen parent(s)* Yes No Parent with mental illness* Yes No Family Experiences and Stressors, select Yes or NoYoung parents* Yes No Child with a disability or chronic health condition* Yes No Parent with a disability or chronic condition* Yes No Parent with mental health issue(s)* Yes No High school diploma or equivalency not attained* Yes No Low income* Yes No Recent immigrant or refugee family* Yes No Substance use disorder* Yes No Foster care or other temporary caregiver* Yes No Child abuse or neglect* Yes No Parent incarcerated* Yes No Housing instability* Yes No Very low birth rate and preterm birth* Yes No Death in the immediate family* Yes No Intimate partner violence* Yes No Military deployment* Yes No Rights & ResponsibilitiesChildren and families receiving services are entitled to certain rights and have certain responsibilities Rights Families participating in the Child & Family Resource Center Program have the right to; ongoing participation in the program which includes the development of an individualized plan; periodic review and assessment of needs; and appropriate revisions of the plan. Refuse or end services at any time. Referral to other provider services at any time, including upon ending the PAT program. Obtain, upon request, one's own record. Confidentiality of records, both electronic and hard copy. Records will be made available only to those individuals who monitor the program such as funders and credentialing organizations, and of course, to the individual whom the record is about, if so requesting. The review of records by funders and credentialing organizations will only be used to determine the program's compliance to work plans and critical elements. Report any dissatisfaction with the program content or actions of program staff to the program manager. All complaints and/or grievances will be handled according to agency policy. Responsibilities Families participating in the Child & Family Resource Center Program have the following responsibilities; Punctuality: It is very important that families make every effort to arrive to playgroup, field trips, and any other CFA sponsored events on time. This is to minimize disruption to the ongoing program and to ensure all families are receiving quality services. Families may be asked to leave the playgroup or activity if they are late. Chronic lateness may also be addressed and may be cause for dismissal from the program. Conduct: Parents/Guardians/Caregivers are expected to demonstrate appropriate behavior towards all staff, family members, and other clients. Rude or obscene language, evidence of intoxication or substance abuse, and/or verbal/physical threats towards all staff, family members, or other clients will not be tolerated and may result in immediate termination of services. Further, threats or actions against one's self or others are not protected by confidentiality and may be reported to the appropriate authority. Personal Visit Component: Families have access to free playgroups and group socialization opportunities, field trips, resource and referral services, and education services from trained Parents as Teacher educators. Staff will develop individualized plans for program participants. Rights & Responsibilities* I have read and/or discussed my rights and responsibilities and fully understand and agree to them. Parent signature* Today's Date* MM slash DD slash YYYY
