Enrollment Form

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Enrollment Form

Please use the drop down menu above to select a language for this form. // Por favor utilize el menú desplegable de arriba para seleccionar el lenguaje para este formulario
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Which of our services are you interested in? Please select all that apply*

Early Learning Groups & Classes (birth to age 5)Positive Parenting Programming (Triple P) Workshop SeriesFamily Support ServicesMental Health ServicesI'd like to learn more about what is available
Early Learning Groups & Classes

Little Explorers
- For caregivers and children from 12 months to 36 months
- Child must be 12 months old by September 1, 2024
- Tuesday & Thursday from 1:15 PM - 2:30 PM
- Daly City and East Palo Alto Locations ONLY
Nurturing Families *
- For caregivers and children from 12 months to 36 months
- Child must be 12 months old by September 1, 2024
- Tuesday & Thursday
- Morning Class: 10:00 AM - 12:00 PM
- Afternoon Class: 1:00 PM - 3:00 PM
Preschool *
- For caregivers and children from 3 through 5 years of age
- Child must be 3 years old by September 1, 2024
- Monday, Wednesday, & Friday
- 9:00 AM - 1:00 PM
* Please note that your enrollment is NOT confirmed until you receive an email confirmation.
Positive Parenting Programming

Positive Parenting Program (Triple P) is a proven way of parenting that helps parents learn positive ways to raise children. By joining the program, parents can learn important skills to have a strong bond with their children, help them grow socially and emotionally, and handle difficult behavior in a positive way.

Participation in Triple P requires an 8-week commitment, including:
- Four 2-hour virtual sessions
- Three individualized check-in phone calls
- A final in-person celebratory session (Location TBD)
Space is limited to 10 caregivers per session.

Please click here for more information about the Positive Parenting Program.
Are you interested in enrolling in our Summer Program, upcoming School Year Program, or both?

2023 - 2024 School Year Program
What is your preferred language for Triple P?*

SpanishEnglishNo preference
Locations

Daly City
575 Abbot Ave, Daly City, CA 94014

East Palo Alto
2400 Ralmar Ave, Palo Alto, CA 94303

Redwood City
414 4th Ave, Redwood City, CA 94063
Preferred Location*

Daly CityEast Palo AltoRedwood City

Child #1 Information
Child 1 Full Name*

First NameLast Name
Nickname or Preferred Name
Date of Birth*

MonthDayYear
Date
Gender*

FemaleMaleOther
Program*

Little Explorers (12 months - 36 months)Nurturing Families (12 months - 36 months)Preschool (3 - 5 years old)
Preferred Time*

10 AM - 12 PM1 PM - 3 PMNo preference
Has your child ever gone to preschool regularly (at least two times per week for at least six months)? Preschool might also be called Head Start, Pre-kindergarten, or Transitional Kindergarten. It could be at a center- or home-based preschool, or at a school.

YesWe recently enrolled (less than 6 months ago)Not yet; we are on a waitlistNo; I am trying to find oneNo; I am not interested at this timeNot applicable (too young; child under 3)
Ethnicity*

American Indian or Alaska NativeAsian or Asian AmericanBlack or African AmericanHispanic / Latino / LatinxNative Hawaiian / Pacific IslanderMiddle Eastern or North AfricanNative or Indigenous from Central or South AmericaWhiteMulti-RacialPrefer not to answerOther
Languages child hears at home (please select all that apply)*

EnglishSpanishChineseTagalogVietnameseArabicRussianOther
Child's preferred language*

EnglishSpanishChineseTagalogVietnameseArabicRussianOther
Will your child need any accommodations or medication while on site?*

YesNo
Please share any information about necessary accommodations. If needed, we will reach out to you to discuss.

In a usual week, how often does your family do these things with your child?*

	Not at all	1 to 2 days	3 to 4 days	5 to 6 days	Everyday	Don't know
Read stories or look at picture books
Play music or sing songs
Count things

Would you like to enroll another child?*

YesNo

Child #2 Information
Full Name*

First NameLast Name
Nickname or Preferred Name
Date of Birth*

MonthDayYear
Date
Gender*

FemaleMaleOther
Program*

Little Explorers (12 months - 36 months)Nurturing Families (12 months - 36 months)Preschool (3 - 5 years old)
Preferred Time*

10 AM - 12 PM1 PM - 3 PMNo preference
Has your child ever gone to preschool regularly (at least two times per week for at least six months)? Preschool might also be called Head Start, Pre-kindergarten, or Transitional Kindergarten. It could be at a center- or home-based preschool, or at a school.

YesWe recently enrolled (less than 6 months ago)Not yet; we are on a waitlistNo; I am trying to find oneNo; I am not interested at this timeNot applicable (too young; child under 3)
Ethnicity*

American Indian or Alaska NativeAsian or Asian AmericanBlack or African AmericanHispanic / Latino / LatinxNative Hawaiian / Pacific IslanderMiddle Eastern or North AfricanNative or Indigenous from Central or South AmericaWhiteMulti-RacialPrefer not to answerOther
Languages child hears at home (please select all that apply)*

EnglishSpanishChineseTagalogVietnameseArabicRussianOther
Child's preferred language*

EnglishSpanishChineseTagalogVietnameseArabicRussianOther
Will your child need any accommodations or medication while on site?*

YesNo
Please share any information about necessary accommodations. If needed, we will reach out to you to discuss.

In a usual week, how often does your family do these things with your child?*

	Not at all	1 to 2 days	3 to 4 days	5 to 6 days	Everyday	Don't know
Read stories or look at picture books
Play music or sing songs
Count things

Would you like to enroll another child?*

YesNo

Child #3 Information
Full Name*

First NameLast Name
Nickname or Preferred Name
Date of Birth*

MonthDayYear
Date
Gender*

FemaleMaleOther
Program*

Little Explorers (12 months - 36 months)Nurturing Families (12 months - 36 months)Preschool (3 - 5 years old)
Preferred Time*

10 AM - 12 PM1 PM - 3 PMNo preference
Has your child ever gone to preschool regularly (at least two times per week for at least six months)? Preschool might also be called Head Start, Pre-kindergarten, or Transitional Kindergarten. It could be at a center- or home-based preschool, or at a school.

YesWe recently enrolled (less than 6 months ago)Not yet; we are on a waitlistNo; I am trying to find oneNo; I am not interested at this timeNot applicable (too young; child under 3)
Ethnicity*

American Indian or Alaska NativeAsian or Asian AmericanBlack or African AmericanHispanic / Latino / LatinxNative Hawaiian / Pacific IslanderMiddle Eastern or North AfricanNative or Indigenous from Central or South AmericaWhiteMulti-RacialPrefer not to answerOther
Languages child hears at home (please select all that apply)*

EnglishSpanishChineseTagalogVietnameseArabicRussianOther
Child's preferred language*

EnglishSpanishChineseTagalogVietnameseArabicRussianOther
Will your child need any accommodations or medication while on site?*

YesNo
Please share any information about necessary accommodations. If needed, we will reach out to you to discuss.

In a usual week, how often does your family do these things with your child?*

	Not at all	1 to 2 days	3 to 4 days	5 to 6 days	Everyday	Don't know
Read stories or look at picture books
Play music or sing songs
Count things

Primary Caregiver
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Please send reminders about upcoming classes and events to this email address*

YesNo
Phone Number*
Please enter a valid phone number.
Please text important updates and notifications to this phone number*

YesNo
Family Connections may leave a voicemail at the number provided*

YesNo
Preferred Method(s) of communication:*

EmailTextPhone CallOther
Relationship to child(ren)*

MotherFatherGrandmotherGrandfatherAuntUncleLegal GuardianOther
Gender*

MaleFemaleNonbinaryOther
Preferred language*

EnglishSpanishOther
Ethnicity*

American Indian or Alaska NativeAsian or Asian AmericanBlack or African AmericanHispanic / Latino / LatinxNative Hawaiian / Pacific IslanderMiddle Eastern or North AfricanNative or Indigenous from Central or South AmericaWhiteMulti-RacialPrefer not to answerOther
What is the highest grade or year of school that you have completed?*

Less than high schoolSome high schoolHigh school diploma or equivalentSome collegeTwo-year degreeFour-year Bachelor or equivalent degreeSome graduate schoolMasters degreePh.D, J.D., M.D. or equivalent
Please list any food, medication or other allergens that you are allergic to:
Do you have any disabilities?*

YesNoChoose not to disclose
Do you need any accommodations while on site? Please explain:
Parent volunteers enrich the experience of our community. Children benefit from seeing the adults in their life leading activities and supporting their school. Please help us learn about your areas of interest, expertise and talents.

Arts and CraftsComputerConstructionCooking and/or BakingDancingEvent PlanningFundraisingGardeningGrant WritingNursing or Medically trainedMusic / InstrumentsSportsReading to childrenScienceOther
Will another caregiver be participating in programming?*

YesNo

Caregiver #2
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Please send reminders about upcoming classes and events to this email address*

YesNo
Phone Number*
Please enter a valid phone number.
Please text important updates and notifications to this phone number*

YesNo
Family Connections may leave a voicemail at the number provided*

YesNo
Preferred Method(s) of communication:*

EmailTextPhone CallOther
Relationship to child(ren)*

MotherFatherGrandmotherGrandfatherAuntUncleLegal GuardianOther
Gender*

MaleFemaleNonbinaryOther
Preferred language*

EnglishSpanishOther
Ethnicity*

American Indian or Alaska NativeAsian or Asian AmericanBlack or African AmericanHispanic / Latino / LatinxNative Hawaiian / Pacific IslanderMiddle Eastern or North AfricanNative or Indigenous from Central or South AmericaWhiteMulti-RacialPrefer not to answerOther
What is the highest grade or year of school that you have completed?*

Less than high schoolSome high schoolHigh school diploma or equivalentSome collegeTwo-year degreeFour-year Bachelor or equivalent degreeSome graduate schoolMasters degreePh.D, J.D., M.D. or equivalent
Please list any food, medication or other allergens that you are allergic to:
Do you have any disabilities?*

YesNoChoose not to disclose
Do you need any accommodations while on site? Please explain:
Parent volunteers enrich the experience of our community. Children benefit from seeing the adults in their life leading activities and supporting their school. Please help us learn about your areas of interest, expertise and talents.

Arts and CraftsComputerConstructionCooking and/or BakingDancingEvent PlanningFundraisingGardeningGrant WritingNursing or Medically trainedMusic / InstrumentsSportsReading to childrenScienceOther
Will another caregiver be participating in programming?*

YesNo

Caregiver #3
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Please send reminders about upcoming classes and events to this email address*

YesNo
Phone Number*
Please enter a valid phone number.
Please text important updates and notifications to this phone number*

YesNo
Family Connections may leave a voicemail at the number provided*

YesNo
Preferred Method(s) of communication:*

EmailTextPhone Call / VoicemailOther
Relationship to child(ren)*

MotherFatherGrandmotherGrandfatherAuntUncleLegal GuardianOther
Gender*

MaleFemaleNonbinaryOther
Preferred language*

EnglishSpanishOther
Ethnicity*

American Indian or Alaska NativeAsian or Asian AmericanBlack or African AmericanHispanic / Latino / LatinxNative Hawaiian / Pacific IslanderMiddle Eastern or North AfricanNative or Indigenous from Central or South AmericaWhiteMulti-RacialPrefer not to answerOther
What is the highest grade or year of school that you have completed?*

Less than high schoolSome high schoolHigh school diploma or equivalentSome collegeTwo-year degreeFour-year Bachelor or equivalent degreeSome graduate schoolMasters degreePh.D, J.D., M.D. or equivalent
Please list any food, medication or other allergens that you are allergic to:
Do you have any disabilities?*

YesNoChoose not to disclose
Do you need any accommodations while on site? Please explain:
Parent volunteers enrich the experience of our community. Children benefit from seeing the adults in their life leading activities and supporting their school. Please help us learn about your areas of interest, expertise and talents.

Arts and CraftsComputerConstructionCooking and/or BakingDancingEvent PlanningFundraisingGardeningGrant WritingNursing or Medically trainedMusic / InstrumentsSportsReading to childrenScienceOther

Household Information

Please share the number of individuals living in your household*

	How many are in your household?
Adults (including yourself)
Children birth-2
Children 3-5
Children 6-10
Children over 10

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your total family annual income?*

$0 - $10,000$10,001 - $20,000$20,001 - $30,000$30,001 - $40,000$40,001 - $50,000$50,001 - $60,000$60,001 - $70,000$70,001 - $80,000$80,001 - $90,000$90,001 - $100,000$100,001 - $120,000$120,001 - $140,000$140,001 - $160,000$160,001 - $180,000$180,001 - $200,000over $200,0000
Does your family need assistance accessing any of the following resources?*

DiapersChildcare servicesBasic Needs (e.g., food assistance, clothing assistance, utility bill assistance, emergency financial assistance)Developmental, Behavioral, and/or mental health services for your child(ren) (e.g., speech & language therapy, ABA (applied behavior analysis), parent-child support groups, play therapy)Health Insurance (can include private insurance, provided by an employer, Covered California, MediCal, Medicare)Employment (e.g., job placement, career counseling, resume writing, job training, enough hours)Transportation (e.g., public transportation, ride-sharing, taxis, car rentals)Housing/Shelter servicesLegal (e.g., legal consultation, legal aid, family law services)Mental Health for yourself or another adult in your household (e.g., therapy, counseling, support groups)Domestic violence support servicesDoes not apply I have the services I needOther

Please answer how often the statement provided is true for you and your family within the past month.*

	Almost always	Most of the time	Sometimes	Hardly ever	Never
I have enough food to feed my family.
I am worried about our housing.
I feel like I need help with my mental health: sadness, anxiety, or other problems.
I feel concerned about my child's behavior or development.
Someone in my life makes me feel threatened or unsafe.
I worry that someone in my close family (including myself) has a drug or alcohol problem.
I have friends and family to turn to for support.
I feel confident in my ability to nurture and support the development of my child.
I have enough money to take care of my family’s needs.

Have you participated in Family Connections programming in the past?*

Yes - Returning FamilyNo - New Family
How did you hear about Family Connections?

Family or FriendMedical or Mental Health ProfessionalTeacherInternet SearchSocial MediaOther
Should be Empty:

Enrollment Form

Child #1 Information

Child #2 Information

Child #3 Information

Primary Caregiver

Caregiver #2

Caregiver #3

Household Information