The ABCXYZ Partnership for Children is gathering information about families receiving Smart Start Services. This information will be used to determine the number of families being served by Smart Start and to determine the number of services each family receives. This information will not change the services you receive now or in the future. This information will be shared only with staff at the ABCXYZ Partnership for Children and the Smart Start evaluation team. We would like for you to provide as much of this information as possible.
 

CHILD’S BIRTHDATE                                                                                                 CHILD’S GENDER

CHILD’S SOCIAL SECURITY NUMBER __ __ __ - __ __ - __ __ __ __

CHILD’S NAME

MOTHER’S NAME

MOTHER’S SOCIAL SECURITY NUMBER __ __ __ - __ __ - __ __ __ __

MOTHER’S EDUCATIONAL LEVEL

FAMILY SIZE

CHILD’S RACE/ETHNICITY (circle one) African-American                 Asian             White             Multi - Racial Hispanic                 Middle-Eastern             Other (specify) __________________

FAMILY INCOME (circle one) $0 - 4,999 $5,000 - 12,499 $12,500 - 14,999 $15,000 - 17,499 $17,500 - 19,999 $20,000 - 22,499 $22,500 - 24,999 $25,000 - 27,499 $27,500 - 29,999 $30,000 - 34,499 $34,500 and above

To Be Filled Out By Project:

_______________________ Transportation _______________________ Transportation

 
_____ I give my permission to share the above information with the ABCXYZ Partnership for Children.
_____ I do not want to share the above information with the ABCXYZ Partnership for Children. I understand that this decision will not affect my Smart Start services now or in the future.

____________________________________________         _________________________
Parent’s Signature                                                                     Date