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
Participant's Birth Date*

MonthDayYear
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
#1 Primary Phone Number*
#2 Primary Phone Number
Preferred Membership*
Are you signed up with Alta Regional Center?*

YesNo
If you are with Alta do you plan to use your social rec funds?

YesNo
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.
Should be Empty:

Welcome to Kinship