Parent InformationYour Name(Required) First Middle Initial Last Your Address Street Address City ZIP Code Preferred Language Date of Birth MM slash DD slash YYYY Gender F M O Home Phone(Required)Alternate PhoneIs it OK to leave a message? Y N Your Email Address(Required) Preferred Contact Call Text Email Family Information1st Time Parent Y N Pregnant Y N Due Date MM slash DD slash YYYY Prenatal Care Y N Child's Name First Last Date of Birth MM slash DD slash YYYY Gender F M O Family Emergency Contact and Phone Programs Healthy Families Tehama, Tehama County Public Health Help Me Grow/Parents as Teachers HV, Tehama County Dept. of Education (use for car seat referral) Early Head Start/Head Start, Northern CA Child Development, Inc State Preschool, Tehama County Dept. of Education Family Child Care Home Education Network, Tehama County Dept. of Edu. Special Education Local Plan Area, Tehama County Dept. of Education Family and Community Engagement Services, Shasta County Office of Ed. Referral SourceFamily Self-Referral Y N CW HVP Y N Client was verbally advised of referral Y N Organization Unit/Dept Name of Person or Agency Completing the Form Referred By (Staff Name) PhoneEmail Referral Date MM slash DD slash YYYY Additional Information – Please add any information that would help the receiving program. Include if the parent is interested in a car seat check or new car seat here. PDF version of English Pregnancy to Preschool Form
