PROMIS Eligible Child Demographic Form Intake Form 1.pdf 2026

1. Click ‘Get Form’ to open the PROMIS Eligible Child Demographic Form Intake Form 1.pdf in the editor.
2. Begin by entering the date at the top of the form. This helps track when the information was collected.
3. Fill in the family name and eligible child’s name, including first name, middle initial, and last name. If applicable, add a nickname.
4. Provide the child's date of birth and select their gender from the options provided.
5. Indicate the child's ethnicity and race by checking only one option from each respective section.
6. Specify the language spoken at home and assess how well the child speaks English by selecting from the given options.
7. Address any concerns expressed by program staff or other sources regarding the child's health and development.
8. List who will care for the child besides the head of household, checking all applicable options.
9. Complete contact information, including addresses and phone numbers for both living arrangements and mailing purposes.
10. Fill out insurance details, including provider name, policy number, effective date, and whether dental coverage is included.
11. Finally, indicate if full-day childcare is needed and specify which type of program will be utilized.

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