The following information is to help the ABCXYZ County Partnership for Children collect data about families receiving Smart Start services to examine its effectiveness. This information will be used to determine the number of families served by Smart Start and the type of services each family receives. This information with not change the services you receive now or in the future. It will only be shared with the ABCXYZ County Partnership for Children and the Smart Start Evaluation Team.

( ) I give my permission for the data to be used by the ABCXYZ County Partnership for Children.

( ) I do not want the ABCXYZ County Partnership for Children to receive any information about my child and my family. I understand that this will not affect my Smart Start services now or in the future.

__________________________                         __________________________
Parent/Guardian’s Signature                         Date
                            __________________________ 
                                Child’s name 

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FAMILY SIZE (Indicate the number of people who live in this household)		ANNUAL GROSS INCOME (Indicate the range of annual gross income - before taxes and including AFDC - for the family)
TWO	____________	$0 - 10,000	____________
THREE	____________	$10,001 - 20,000	____________
FOUR	____________	$20,001 - 30,000	____________
FIVE	____________	$30,001 - 40,000	____________
SIX	____________	$40,001 - 50,000	____________
SEVEN	____________	$50,001+	____________
EIGHT or more	____________

Is this a single parent household? Yes ____; No____
Mother’s name ________________________ SSN ______________
Who is the primary caregiver? Check one.
Mother:___ Father:___ Grandparent:___ Teen Mom:___ Teen Dad:___ Other:___
Circle the highest education level of the mother:
1 2 3 4 5 6 7 8 9 10 11 12 GED 13 14 15 16 17+

Please provide the social security number for each child (age 0 - 5)
Child’s name __________________ SSN __________________
Date of birth ___________________ Male _____ Female _____
                month day year

Please provide the social security number for each child (age 0 - 5)
Child’s name __________________ SSN __________________
Date of birth ___________________ Male _____ Female _____
                month day year

Please provide the social security number for each child (age 0 - 5)
Child’s name __________________ SSN __________________
Date of birth ___________________ Male _____ Female _____
                month day year

List names and SSN of additional children (ages 0 - 5) on back.