Pre-Registration Form

Pre-Registration Form
Welcome to Kinship

Please fill out this pre-registration form to be considered for one of our social groups at the Kinship Center. After submitting this form, we will contact you to schedule an interview to learn more about your child and family. During this meeting, we will discuss your child's needs, our program offerings, and how we can best support them here at Kinship.
Parent/ Guardian #1 Name

First NameLast Name
Parent/Guardian #2 Name

First NameLast Name
Participants Name

First NameMiddle NameLast Name
Participants Birth Date

MonthDayYear
Date
Participant's Gender
Address

Street Address

Street Address Line 2

CityState

Zip Code
Primary E-mail
example@example.com
Secondary E-mail
(optional)
Preferred Start Date

MonthDayYear
Date
#1 Primary Phone Number
Format: (000) 000-0000.
#2 Primary Phone Number
Format: (000) 000-0000.
Preferred Membership
Are you signed up with Alta Regional Center?
If you are with Alta do you plan to use your social rec funds?
Tell us about your or the participant and some of your/their interests.
Additional Comments/interests or support your needing.
If not full-time, please indicate preferred schedule.
Are you signed up with Alta Regional Center? (hide)
Preferred Start Date (hide)
Participant's Birth Date (hide)

MonthDayYear
Should be Empty:

Welcome to Kinship