Welcome to SAFEchild Advocacy Center
Household information - caregiver(s) and child(ren) demographics
How many children in the family are scheduled for an appointment with SAFEchild Advocacy Center?
*
Please Select
1 child
2 children
3 children
4 children
5 children
6 children
Number of children scheduled at SAFEchild
How many households are there in the family?
*
Please Select
1 household
2 households
more than 2 households
Does the child live at one residence, or go between two or more different households (ex: mom's house & dad's house)
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Next
Child
Child #1 Demographics
Legal Name
*
First Name
Middle Name
Last Name
Preferred Name
Date of Birth
*
-
Month
-
Day
Year
Gender at Birth
*
Please Select
Female
Male
Other
Gender Identity
*
Please Select
Female
Male
Other
Preferred Pronouns
*
Please Select
She/Her/Hers
He/Him/His
They/Them/Their
Other
Race Ethnicity
*
School or Educational Center Name
*
Grade or Education Level
*
Please Select
Not Enrolled
Daycare Only
Preschool
Pre-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
College or University
Child's Mobile Phone Number (if applicable)
Please enter a valid phone number.
Child's Email (if applicable)
example@example.com
Medicaid?
*
Please Select
Yes
No
Medicaid #
If NO Medicaid, please list Medical insurance provider (or "none"):
Is there anything about Child 1 you want us to know prior to the appointment?
Child
Child #2 Demographics
Legal Name
*
First Name
Middle Name
Last Name
Preferred Name
Date of Birth
*
-
Month
-
Day
Year
Gender at Birth
*
Please Select
Female
Male
Other
Gender Identity
*
Please Select
Female
Male
Other
Preferred Pronouns
*
Please Select
She/Her/Hers
He/Him/His
They/Them/Their
Other
Race Ethnicity
*
School or Educational Center Name
*
Grade or Education Level
*
Please Select
Not Enrolled
Daycare Only
Preschool
Pre-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
College or University
Child's Mobile Phone Number (if applicable)
Please enter a valid phone number.
Child's Email (if applicable)
example@example.com
Medicaid?
*
Please Select
Yes
No
Medicaid #
If NO Medicaid, please list Medical insurance provider (or "none"):
Is there anything about Child 2 you want us to know prior to the appointment?
Child
Child #3 Demographics
Legal Name
*
First Name
Middle Name
Last Name
Preferred Name
Date of Birth
*
-
Month
-
Day
Year
Gender at Birth
*
Please Select
Female
Male
Other
Gender Identity
*
Please Select
Female
Male
Other
Preferred Pronouns
*
Please Select
She/Her/Hers
He/Him/His
They/Them/Their
Other
Race Ethnicity
*
School or Educational Center Name
*
Grade or Education Level
*
Please Select
Not Enrolled
Daycare Only
Preschool
Pre-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
College or University
Child's Mobile Phone Number (if applicable)
Please enter a valid phone number.
Child's Email (if applicable)
example@example.com
Medicaid?
*
Please Select
Yes
No
Medicaid #
If NO Medicaid, please list Medical insurance provider (or "none"):
Is there anything about Child 3 you want us to know prior to the appointment?
Child
Child #4 Demographics
Legal Name
*
First Name
Middle Name
Last Name
Preferred Name
Date of Birth
*
-
Month
-
Day
Year
Gender at Birth
*
Please Select
Female
Male
Other
Gender Identity
*
Please Select
Female
Male
Other
Preferred Pronouns
*
Please Select
She/Her/Hers
He/Him/His
They/Them/Their
Other
Race Ethnicity
*
School or Educational Center Name
*
Grade or Education Level
*
Please Select
Not Enrolled
Daycare Only
Preschool
Pre-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
College or University
Child's Mobile Phone Number (if applicable)
Please enter a valid phone number.
Child's Email (if applicable)
example@example.com
Medicaid?
*
Please Select
Yes
No
Medicaid #
If NO Medicaid, please list Medical insurance provider (or "none"):
Is there anything about Child 4 you want us to know prior to the appointment?
Child
Child #5 Demographics
Legal Name
*
First Name
Middle Name
Last Name
Preferred Name
Date of Birth
*
-
Month
-
Day
Year
Gender at Birth
*
Please Select
Female
Male
Other
Gender Identity
*
Please Select
Female
Male
Other
Preferred Pronouns
*
Please Select
She/Her/Hers
He/Him/His
They/Them/Their
Other
Race Ethnicity
*
School or Educational Center Name
*
Grade or Education Level
*
Please Select
Not Enrolled
Daycare Only
Preschool
Pre-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
College or University
Child's Mobile Phone Number (if applicable)
Please enter a valid phone number.
Child's Email (if applicable)
example@example.com
Medicaid?
*
Please Select
Yes
No
Medicaid #
If NO Medicaid, please list Medical insurance provider (or "none"):
Is there anything about Child 5 you want us to know prior to the appointment?
Child
Child #6 Demographics
Legal Name
*
First Name
Middle Name
Last Name
Preferred Name
Date of Birth
*
-
Month
-
Day
Year
Gender at Birth
*
Please Select
Female
Male
Other
Gender Identity
*
Please Select
Female
Male
Other
Preferred Pronouns
*
Please Select
She/Her/Hers
He/Him/His
They/Them/Their
Other
Race Ethnicity
*
School or Educational Center Name
*
Grade or Education Level
*
Please Select
Not Enrolled
Daycare Only
Preschool
Pre-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
College or University
Child's Mobile Phone Number (if applicable)
Please enter a valid phone number.
Child's Email (if applicable)
example@example.com
Medicaid?
*
Please Select
Yes
No
Medicaid #
If NO Medicaid, please list Medical insurance provider (or "none"):
Is there anything about Child 6 you want us to know prior to the appointment?
Back
Next
Household
Household #1 Information
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How many adults (18yo and up) live here?
*
Please Select
1 adult
2 adults
3 adults
4 adults
5 adults
6 adults
more than 6 adults
1 - Adult Caregiver Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Relationship to child
*
Race Ethnicity
*
Gender Identity
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
2 - Adult Caregiver Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Relationship to child
*
Race Ethnicity
*
Gender Identity
*
Phone Number
Please enter a valid phone number.
Email
example@example.com
3 - Adult Caregiver Name
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
Race Ethnicity
How many children (17yo and under) live here?
*
Please Select
1 child
2 children
3 children
4 children
5 children
6 children
7 children
8 children
9 children
10 children
more than 10 children
Household
Household #2 Information
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How many adults (18yo and up) live here?
*
Please Select
1 adult
2 adults
3 adults
4 adults
5 adults
6 adults
more than 6 adults
1 - Adult Caregiver Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Relationship to child
*
Race Ethnicity
*
Gender Identity
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
2 - Adult Caregiver Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Relationship to child
*
Race Ethnicity
*
Gender Identity
*
Phone Number
Please enter a valid phone number.
Email
example@example.com
3 - Adult Caregiver Name
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
Race Ethnicity
How many children (17yo and under) live here?
*
Please Select
1 child
2 children
3 children
4 children
5 children
6 children
7 children
8 children
9 children
10 children
more than 10 children
Household(s) for Child 1
Household information
Where does Child 1 live?
*
Please Select
Household 1
Household 2
Both
Other
Household
Child 1 - Other Household Information
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How many adults (18yo and up) live here?
*
Please Select
1 adult
2 adults
3 adults
4 adults
5 adults
6 adults
more than 6 adults
1 - Adult Caregiver Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Relationship to child
*
Race Ethnicity
*
Gender Identity
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
2 - Adult Caregiver Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Relationship to child
*
Race Ethnicity
*
Gender identity
*
Phone Number
Please enter a valid phone number.
Email
example@example.com
3 - Adult Caregiver Name
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
Race Ethnicity
How many children (17yo and under) live here?
*
Please Select
1 child
2 children
3 children
4 children
5 children
6 children
7 children
8 children
9 children
10 children
more than 10 children
Household(s) for Child 2
Household information
Where does Child 2 live?
*
Please Select
Household 1
Household 2
Both
Other
Household
Child 2 - Other Household Information
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How many adults (18yo and up) live here?
*
Please Select
1 adult
2 adults
3 adults
4 adults
5 adults
6 adults
more than 6 adults
1 - Adult Caregiver Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Relationship to child
*
Race Ethnicity
*
Gender Identity
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
2 - Adult Caregiver Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Relationship to child
*
Race Ethnicity
*
Gender Identity
*
Phone Number
Please enter a valid phone number.
Email
example@example.com
3 - Adult Caregiver Name
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
Race Ethnicity
How many children (17yo and under) live here?
*
Please Select
1 child
2 children
3 children
4 children
5 children
6 children
7 children
8 children
9 children
10 children
more than 10 children
Household(s) for Child 3
Household information
Where does Child 3 live?
*
Please Select
Household 1
Household 2
Both
Other
Household
Child 3 - Other Household Information
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How many adults (18yo and up) live here?
*
Please Select
1 adult
2 adults
3 adults
4 adults
5 adults
6 adults
more than 6 adults
1 - Adult Caregiver Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Relationship to child
*
Race Ethnicity
*
Gender Identity
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
2 - Adult Caregiver Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Relationship to child
*
Race Ethnicity
*
Gender Identity
*
Phone Number
Please enter a valid phone number.
Email
example@example.com
3 - Adult Caregiver Name
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
Race Ethnicity
How many children (17yo and under) live here?
*
Please Select
1 child
2 children
3 children
4 children
5 children
6 children
7 children
8 children
9 children
10 children
more than 10 children
Household(s) for Child 4
Household information
Where does Child 4 live?
*
Please Select
Household 1
Household 2
Both
Other
Household
Child 4 - Other Household Information
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How many adults (18yo and up) live here?
*
Please Select
1 adult
2 adults
3 adults
4 adults
5 adults
6 adults
more than 6 adults
1 - Adult Caregiver Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Relationship to child
*
Race Ethnicity
*
Gender Identity
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
2 - Adult Caregiver Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Relationship to child
*
Race Ethnicity
*
Gender Identity
*
Phone Number
Please enter a valid phone number.
Email
example@example.com
3 - Adult Caregiver Name
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
Race Ethnicity
How many children (17yo and under) live here?
*
Please Select
1 child
2 children
3 children
4 children
5 children
6 children
7 children
8 children
9 children
10 children
more than 10 children
Household(s) for Child 5
Household information
Where does Child 5 live?
*
Please Select
Household 1
Household 2
Both
Other
Household
Child 5 - Other Household Information
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How many adults (18yo and up) live here?
*
Please Select
1 adult
2 adults
3 adults
4 adults
5 adults
6 adults
more than 6 adults
1 - Adult Caregiver Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Relationship to child
*
Race Ethnicity
*
Gender Identity
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
2 - Adult Caregiver Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Relationship to child
*
Race Ethnicity
*
Gender Identity
*
Phone Number
Please enter a valid phone number.
Email
example@example.com
3 - Adult Caregiver Name
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
Race Ethnicity
How many children (17yo and under) live here?
*
Please Select
1 child
2 children
3 children
4 children
5 children
6 children
7 children
8 children
9 children
10 children
more than 10 children
Household(s) for Child 6
Household information
Where does Child 6 live?
*
Please Select
Household 1
Household 2
Both
Other
Household
Child 6 - Other Household Information
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How many adults (18yo and up) live here?
*
Please Select
1 adult
2 adults
3 adults
4 adults
5 adults
6 adults
more than 6 adults
1 - Adult Caregiver Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Relationship to child
*
Race Ethnicity
*
Gender Identity
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
2 - Adult Caregiver Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Relationship to child
*
Race Ethnicity
*
Gender Identity
*
Phone Number
Please enter a valid phone number.
Email
example@example.com
3 - Adult Caregiver Name
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
Race Ethnicity
How many children (17yo and under) live here?
*
Please Select
1 child
2 children
3 children
4 children
5 children
6 children
7 children
8 children
9 children
10 children
more than 10 children
Submit
Should be Empty: