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PROMIS Eligible Child Demographic Form Intake Form 1.pdf 2026
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- Click ‘Get Form’ to open the PROMIS Eligible Child Demographic Form Intake Form 1.pdf in the editor.
- Begin by entering the date at the top of the form. This helps track when the information was collected.
- Fill in the family name and eligible child’s name, including first name, middle initial, and last name. If applicable, add a nickname.
- Provide the child's date of birth and select their gender from the options provided.
- Indicate the child's ethnicity and race by checking only one option from each respective section.
- Specify the language spoken at home and assess how well the child speaks English by selecting from the given options.
- Address any concerns expressed by program staff or other sources regarding the child's health and development.
- List who will care for the child besides the head of household, checking all applicable options.
- Complete contact information, including addresses and phone numbers for both living arrangements and mailing purposes.
- Fill out insurance details, including provider name, policy number, effective date, and whether dental coverage is included.
- Finally, indicate if full-day childcare is needed and specify which type of program will be utilized.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2008 | 4 Satisfied (27 Votes) |
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