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*	Question - Required - Families qualify for services if they are residents of Oak Park or River Forest, pregnant or caregiving for a child under age 3-5 and meet one or more of the following eligibility criteria (please check all that you know apply): Please make at least 1 selection from the choices below. Homeless or unstable housing Child Abuse/ neglect Court appointed legal guardian or foster family Substance Abuse Low income Child with developmental delays/disabilities/chronic health conditions Substance abuse Low parent education Incarcerated parent in federal or state prison or local jail or released within past year Parent with mental illness Parent with disability or chronic health condition Domestic or family violence Military Family (Parent/Guardian currently deployed or is within 2 years of returning from a military deployment as an active duty member of the armed forces). Very low birth weight (3.3 lbs or less) Death in immediate family Recent immigrant or refugee Uninsured/underinsured Single parent Relative Primary (child being raised by grandparent(s) or parent substitute) Parental isolation/lack of support system Multiple children under age five First time or anxious parent English as a second language
	Parent/Caregiver Information * Name: First Required  Last Required        Email   Street 1:   Street 2: * City/State/ZIP: City State   ZIP Required    AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AS FM GU MH MP PR PW VI AA AE AP AB BC MB NB NL NS NT NU ON PE QC SK YT None     Phone Number:   Gender: Male Female   Date of Birth: Date of Birth: Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027   Yes, I would like to receive email from Easterseals   Yes, I would like to receive postal mail from Easterseals   Keep me logged in. What's this? Remembers your login information for your convenience. Use only on trusted, private computers. Privacy Policy
*	Question - Required - Primary language spoken:
	Secondary contact for family:
	Question - Not Required - Name:
	Question - Not Required - Phone number:
	Question - Not Required - Relationship:
	If client is pregnant:
	Question - Not Required - Date of expected delivery: Month Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year Year 2037 2036 2035 2034 2033 2032 2031 2030 2029 2028 2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922
	Question - Not Required - Use the space below to share any other useful information regarding this family:
	Referral Source Information
*	Question - Required - Is caregiver aware of this referral? Please select response Yes No
*	Question - Required - Name of person completing referral:
	Question - Not Required - Referring agency name:
*	Question - Required - Phone number:
	Question - Not Required - Email address:
	Who can we contact if we cannot reach you using the above contact information?
	Question - Not Required - Name:
	Question - Not Required - Phone number:

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