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Criterion Child Enrichment

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Welcome Family

Welcome Family Registration Form

Please complete the following information to register for Welcome Family:

Fields marked with * are required.

Caregiver Name *

Caregiver Date of Birth

Relationship to Baby

Mother

Father

Foster Parent

Adoptive Parent

Grandparent

Baby Name

Baby Gender

Male

Female

Baby Date of Birth *

If twin, triplet, etc., please enter multiple name(s):

Baby Name(s)

Street Address

City *

Zip Code

Phone *

Alternate Phone

Ethnicity

Hispanic

Non-Hispanic

Prefer not to answer

Race

White

Black

Asian/Pacific Islander

American Indian/Alaska Native

Multi-racial

Other

Prefer not to answer

Preferred Language *

Arabic

Chinese

English

Haitian Creole

Portuguese

Russian

Spanish

Vietnamese

Other

Please specify:

Do you need an interpreter? *

Yes

No

How did you hear about us? *

Hospital

Community Health Center or Clinic

Community/Social Service Agency

Caregiver Medical Provider

Friend or Relative

Pediatrician

Self

Other

Please specify:

Please enter the following security code:

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