Family Enrollment Form | Help Me Grow Alabama

Parent or Guardian Name*

First Last

Relationship to Child*

Parent or Guardian Address*

Street Address Address Line 2 City ZIP Code

Phone*

Email*

Please indicate the language you would like to be contacted in:*

Best time to contact you:*

Morning
Afternoon

For grant purposes, please include the following:

Race*

Ethnicity*

Please indicate your family's health insurance (Insurance is not required to receive Help Me Grow Alabama services)

Parent/Guardian Insurance*

Child(ren)'s Insurance*

How did you hear about Help Me Grow?*

Please indicate specific Community Agency/Health Care Provider/Other:

How can we best assist you? (check all that apply)

Answer a Question/Concern About a Child
Help You Find Community Resources
Send Age-Appropriate Activity Sheets
Send you the child development screening tool "Ages & Stages Questionnaire (ASQ)"

Child 1 Information

Child's Name*

First Middle Last

Child's Date of Birth or Due Date*

Was Child Born Early?*

Yes
No

How Many Weeks Early?

Child's Gender

Male
Female

Concerns/Reasons for Referral

Child 2 Information

Child's Name

First Middle Last

Child's Date of Birth or Due Date

Was Child Born Early?

Yes
No

How Many Weeks Early?

Child's Gender

Male
Female

Concerns/Reasons for Referral

Child 3 Information

Child's Name

First Middle Last

Child's Date of Birth or Due Date

Was Child Born Early?

Yes
No

How Many Weeks Early?

Child's Gender

Male
Female

Concerns/Reasons for Referral

Additional Comments

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ENROLL TODAY!

AN ONLINE ENROLLMENT FORM

Online Enrollment Form

Child 1 Information

Child 2 Information

Child 3 Information

Every family will have the desire, resources, and confidence to make the best decision for their child’s development. Also, every child will be screened using a valid, evidenced-based tool starting at birth.

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Help Me Grow Alabama