FUN Application

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Families Understanding Nurturing (FUN)

Parenting Support Group Initiative

Cornerstone Family Worship Center Church of God

1918 West 5th Street / Post Office Box 444
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Check Appropriate Box* This field is required.
Families Understanding Nurturing (FUN)
Parent Support Group (Must have successfully completed FUN Program)
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Name* This field is required.Name of Parent(s)
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Parent Email* This field is required.
example@example.com
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Address * This field is required.
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County of Residence* This field is required.
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Cell Phone Number* This field is required.
Area Code
Phone Number
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Home Phone Number
Area Code
Phone Number
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Work Phone Number
Area Code
Phone Number
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CHILDREN’S INFORMATION* This field is required.Boxes will expand upon typing
First & Last Name
Age
Date of Birth
Gender (M or F)
Child Care Site or Grade in School
Name of School Attending
Child 1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Child 2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Child 3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Child 4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
Child 5
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Row 4, Column 5
Child 1
Child 2
Child 3
Child 4
Child 5
First & Last Name
Row 0, Column 0
Age
Row 0, Column 1
Date of Birth
Row 0, Column 2
Gender (M or F)
Row 0, Column 3
Child Care Site or Grade in School
Row 0, Column 4
Name of School Attending
Row 0, Column 5
First & Last Name
Row 1, Column 0
Age
Row 1, Column 1
Date of Birth
Row 1, Column 2
Gender (M or F)
Row 1, Column 3
Child Care Site or Grade in School
Row 1, Column 4
Name of School Attending
Row 1, Column 5
First & Last Name
Row 2, Column 0
Age
Row 2, Column 1
Date of Birth
Row 2, Column 2
Gender (M or F)
Row 2, Column 3
Child Care Site or Grade in School
Row 2, Column 4
Name of School Attending
Row 2, Column 5
First & Last Name
Row 3, Column 0
Age
Row 3, Column 1
Date of Birth
Row 3, Column 2
Gender (M or F)
Row 3, Column 3
Child Care Site or Grade in School
Row 3, Column 4
Name of School Attending
Row 3, Column 5
First & Last Name
Row 4, Column 0
Age
Row 4, Column 1
Date of Birth
Row 4, Column 2
Gender (M or F)
Row 4, Column 3
Child Care Site or Grade in School
Row 4, Column 4
Name of School Attending
Row 4, Column 5
1 of 5
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Will your child/ children be attending with you?* This field is required.
YESNO
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Other caretakers taking class and their relationship to child/childrenExample: Sally Church/ Grandmother
Name
Relations
Caretaker
Row 0, Column 0
Row 0, Column 1
Caretaker
Row 1, Column 0
Row 1, Column 1
Caretaker
Row 2, Column 0
Row 2, Column 1
Caretaker
Caretaker
Caretaker
Name
Row 0, Column 0
Relations
Row 0, Column 1
Name
Row 1, Column 0
Relations
Row 1, Column 1
Name
Row 2, Column 0
Relations
Row 2, Column 1
1 of 3
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Anyone in the family not taking the classIf yes list who if no simply type N/A
Name
Type Name or N/A
Row 0, Column 0
Type Name or N/A
Row 1, Column 0
Type Name or N/A
Type Name or N/A
Name
Row 0, Column 0
Name
Row 1, Column 0
1 of 2
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Ethnicity* This field is required.
African American
Caucasian
Latino/Hispanic
American Indian/Asian
Other
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Need transportation?* This field is required.Transit ONLY runs in Beaufort County
YESNO
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Are there any medical conditions, medications, or special dietary needs a family member has that we should know about?If YES, please explain
Huge
Large
Normal
Small
Ok
Ok
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How did you find us* This field is required.
Please Be Specific
How did you here about the Program
Row 0, Column 0
Reason for Referral to the program
Row 1, Column 0
Name of Person Making the Referral
Row 2, Column 0
How did you here about the Program
Reason for Referral to the program
Name of Person Making the Referral
Please Be Specific
Row 0, Column 0
Please Be Specific
Row 1, Column 0
Please Be Specific
Row 2, Column 0
1 of 3
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Parent/Caregiver Signature* This field is required.By typing your name below indicates as a Electronic signature
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Date* This field is required.
Date
Month
Day
Year
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Recommended Agency
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Case Worker / Counselor Name
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Case Worker / Counselor Phone Number
Area Code
Phone Number
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Case Worker / Counselor Email* This field is required.
example@example.com
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Parental Consent: By signing above, I accept the services of the Cornerstone Families Understanding Nurturing Program and commit to participate and adhere to program rules and guidelines.
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PHOTOS WILL BE TAKEN OF PARTICIPANTS AS PART OF THE CORNERSTONE FAMILIES UNDERSTANDING NURTURING PROGRAM FOR IN HOUSE PURPOSES ONLY. PHOTOS WILL NOT BE USED FOR SOCIAL MEDIA OR NEWSPAPER PUBLICATION.
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Contact:

Phone: (252) 946-6109 Fax: (252) 623-2056 E-mail: cfwcfunprograms@gmail.com
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