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COMMUNITY LIFE CENTER, INC.

Arthur Eugene & Thelma Adair Head Start/Early Learn

15 Mt. Morris Park

New York City, New York 10035

 

FAMILY INFORMATION CARD

F   _      M____

Medicaid No. _________________                                                                               Center:____________________________

Eligibility: Tanf/Foster/Homeless/Over Income/At or Below                   Disability:  Y/R                      UPK: Y/N

Child’s Full Name: ___________________________________________________________________________

Address: __________________________________________________________________________________

                   Number                     Street                                             Apt.                        Zip Code                                Telephone

 

Birth Date: _____________________          Age: _____                          Date Child Entered: ___________________

Mother’s Name: ________________________________      Employed:                             Yes                         

Father’s Name: _________________________________      Employed:                             Yes                         

Escort:    ________________________________________   Telephone No. _____________________________

Emergency Person: ______________________________      Telephone No. _____________________________

Additional Escorts: _____________________________________ / ___________________________________

Important Numbers: ___________________________________ / ____________________________________

PARENT E-MAIL ADDRESS______________________________________________