The Judy Center Family Intake Form

The Judy Center Family Intake Form

*All information will be kept confidential and only shared with your signed consent*
Which elementary school does or will your child attend based on your current address?

Hurlock ElementaryMaple ElementarySandy Hill Elementary

Please complete for ALL household members*

	Full Name	Relationship to Parent/ Caregiver	Date of Birth	School/ Grade	Gender	Race/ Ethnicity
Parent/ Caregiver
Household Member #1
Household Member #2
Household Member #3
Household Member #4
Household Member #5
Household Member #6
Household Member #7

Are you or anyone in your household currently pregnant?*

NoYes
Enter Due Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
What language(s) do you speak at home?*

EnglishSpanishOther
Where do your children receive before and after care for school?*

At home with parents/relativesAt neighbor's or relative's homeEnrolled in a formal after care program
Enter name of Formal After Care Program*

Are you currently employed?*

	Yes	Name of Company	Full-Time or Part-Time	No
Primary Caregiver/ Guardian
Other Caregiver/ Guardian

Highest Level of Education*

	Less Than High School	High School Diploma	Bachelor's Degree	Graduate Degree
Primary Caregiver
Other Caregiver/ Guardian

Do you have access to health insurance?*

Do any of the children in your household have an active IEP/ IFSP or currently receive special education services?*

YesNo
Does your child/ children have a primary care physician?*

YesNo
Does your child/ children have a dentist?*

YesNo
Does your family participate in any of the following community programs?*

Dorchester Infants & ToddlersHealthy Families DorchesterHead Start/Eary Head Start (ShoreUp!)No
Is your child connected to any behavioral or mental health support?*

NoYes
Name of behavioral or mental health support*
Please Check Any Services That Your Family Would Like Assistance w/ from Judy Center Staff*

Locating Child careChildcare Scholarship VoucherGEDDriver's License / ID CardESLJob Information / Job TrainingUnemployment BenefitsLocating HousingRental AssistanceHousing Choice Voucher Application (Section 8)Child ImmumizationsHealth InsuranceWICSupport with Substance UseMental Health Support for AdultMental Health Support for ChildDevelopmental Screening / Early InterventionTemporary Cash Assistance (TCA)SNAP ( Food Stamps)MEAP (Energy Assistance)Child SupportAccess to foodClothing / School UniformsLegal Assistance (Immigration, Legal Aid, etc.)Interpreter for School and/or Judy Center EventsAt Home Parenting SkillsNone at this timeOther
How did you find out about The Judy Center at Sandy Hill?*
Signature*

Clear
Should be Empty: