GENERAL INFORMATION What is the sex? Female Male child’s ☐ ☐ Date of Birth_____________________________ current age Child’s Is your child adopted? If yes, at what age? ☐No ☐Yes Who is filling out this form? ☐Mother ☐Father guardian (please explain relationship to child) __________________________ ☐Other (please explain) ☐Other The parents are: child’s but not divorced ☐Single ☐Married ☐Divorced ☐Separated together but not married ☐Widowed ☐Living ☐Unknown Main adult contact for child Other adult contact for child Name: Name: Relation to child: Relation to child: Mother Father Mother Father ☐ ☐ ☐ ☐ Other: ________________________ Other: ________________________ ☐ ☐ Address: Same as Address: Same as ☐ child’s ☐ child’s Street address: ____________________ Street address: ____________________ City: ____________________________ City: ____________________________ State: ___________________________ State: ___________________________ Zip: ____________________________ Zip: ____________________________ Home Phone: Home Phone: Cell Phone: Cell phone: Work Phone: Work Phone:
GENERAL INFORMATION What is the child’s sex? ☐ Female ☐ Male Child’s Date of Birth_____________________________ current age Is your child adopted? ☐No ☐Yes If yes, at what age? Who is filling out this form? ☐Mother ☐Father ☐Other guardian (please explain relationship to child) __________________________ ☐Other (please explain) The child’s parents are: ☐Single ☐Married ☐Divorced ☐Separated but not divorced ☐Widowed ☐Living together but not married ☐Unknown Main adult contact for child Other adult contact for child Name: Name: Relation to child: ☐ Mother ☐ Father ☐ Other: ________________________ Relation to child: ☐ Mother ☐ Father ☐ Other: ________________________ Address: ☐ Same as child’s Street address: ____________________ City: ____________________________ State: ___________________________ Zip: ____________________________ Address: ☐ Same as child’s Street address: ____________________ City: ____________________________ State: ___________________________ Zip: ____________________________ Home Phone: Home Phone: Cell Phone: Cell phone: Work Phone: Work Phone:
healthlittoolkit2-tool11b.docx