Lakes Region Community Services Family Info Form Playgroups/Events

Name of Activity*
Parent/Caregiver Name*
First Last
Parent Date of Birth*
MM slash DD slash YYYY
Additional Parent/Caregiver Name (Optional)
First Last
Additional Parent Date of Birth
MM slash DD slash YYYY
Email*
Contact Phone (Optional)
Residence*
City
Child #1 Name*
First Last
Child #1 Date of Birth*
MM slash DD slash YYYY
Child #2 Name
First Last
Child #2 Date of Birth
MM slash DD slash YYYY
Child #3 Name
First Last
Child #3 Date of Birth
MM slash DD slash YYYY
Child #4 Name
First Last
Child #4 Date of Birth
MM slash DD slash YYYY
Child #5 Name
First Last
Child #5 Date of Birth
MM slash DD slash YYYY
Consent*
I understand that my demographic information will be collected and stored within the Family and Community Health Data System and shared with the Division of Public Health. Personally identifiable data is collected for the purpose of program evaluation and reporting required to maintain funding. DPH will not disclose identifying information on families and all data used for reporting purposes is deidentified.*