Enrollment Form for Family Support Services

Mother's Name:

Father's Name:

Guardian's Name:

Child's Name:

Date of Birth:

Social Security Number:

Address:

City:

County:

State:

Zip code:

Phone(s): Home:

Work:

Cell/pager:

E-mail address:

Service Coordinator:

Phone number:

I would like to receive information about our Sibling Groups. Yes No

If yes, please provide the following information:

Sibling's names and Dates of Birth:

I would like my child's grandparents to receive information about our Grandparent Meetings. Yes No

If yes, please complete the information below:

Grandparent's name(s):

Address:

City:

State:

Zip code:

Phone(s): Home:

Work:

Cell/pager:

E-mail address:

Would you like to receive information about our Support and Recreation Groups for Youth with Visual Impairments, ages three through high school? Yes No

I would like to receive information about all other Delta Gamma Center Family Activities and Events. (Examples include parent potlucks, speakers, family retreat, ice skating) Yes No

I would prefer to receive information:

Through the postal service

Via email