HIC Demographic Info

Todays Date

MonthDayYear
Date
Hoover Intergenerational Care Demographic Information
Childs name
Childs date of birth

MonthDayYear
Date
Child's Gender
If child was born prematurely number of weeks premature
Childs ethnicity
Child's birth weight
pounds & ounces
Parent Primary Caregiver name
First MI Last
Relationship to child
Address

Street address

Street Address Line 2

City State ZipPostal CodeState / Province

Postal / Zip Code
Home Telephone
Format: (000) 000-0000.
Cell/Other Telephone
Format: (000) 000-0000.
Work Telephone
Format: (000) 000-0000.
Email address
example@example.com
Childs primary language
Languages spoken in the home
Chllds primary care physician
Clinic name
Clinic/practice mailing address:

City, State & Zip/Postal Code:
Address

Clinicpractice mailing address

Street Address Line 2

City State ZipPostal CodeState / Province

Postal / Zip Code
Telephone
Format: (000) 000-0000.
Email address
example@example.com
Please list any medical conditions that your child has
Please list any other agencies that are involved with your child family
Program Information
Child ID
Date of admission to the program

MonthDayYear
Date
Childs adjusted age in months and days if applicable
Program name
Program ID
Should be Empty: