Forms – FRC Registration

FRC Registration (rev 20220311)

FRC Registration 2022-2023

The Family Resource Center Play & Learn Group Enrollment
This 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 Information
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City 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 Ethnicity
Are 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 Information
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City 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 Ethnicity
Are 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 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 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 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 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 Release
I 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 No
Chronic 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 No
Young 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 & Responsibilities
Children 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

Forms – FRC Registration

FRC Registration (rev 20220311)

The Family Resource Center Play & Learn Group Enrollment

Parent/Guardian Information

Medical & Dental Information

Race and Ethnicity

Second Parent/Guardian Information

Medical & Dental Information

Race and Ethnicity

Child's Information

Medical & Dental Information

Photo Release

Family Assessment

Select Yes or No

Family Experiences and Stressors, select Yes or No

Rights & Responsibilities

Children and families receiving services are entitled to certain rights and have certain responsibilities