Form Overview This form is to be used by families to provide information about their child’s special needs. Which Child Care Advisor have you been working with (if unsure, select "I can't remember")? *Please select your Child Care Advisor...Sandra ZitoRebecca PooleMarg GrovesSadaf AnsariCarrie KoenigSandra CarquezValentinaI can't rememberYour Child's Full Name *Date of Birth *Home AddressSchool NameParent(s)/Guardians *Phone Number *Phone Number *Parent/Guardian Email AddressOther AgenciesDiagnosisThe fields below have character limits in order for the text to fit on our printed forms. If you need to share more information than is allowed on this form, please direct the information to your Home Child Care Advisor so it can be passed along.Equipment/Aids/Supports/Adaptations/Modifications required (if applicable)0 / 180Instructions relation to Equipment/Aids/Support/Adaptations or Modifications0 / 240Goals0 / 240Description of Supports required by the Provider during care0 / 240Signature of Parent / Guardian *Start signing your signature hereYour browser does not support e-Signature field.Today's Date: *SubmitPlease do not fill in this field.
