Child And Family Information Form
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3*Updated 06/24/2012*
ELN Data Fields Form
Child and Family Information
Instructions: This form is designed to give programs information on all the data that is being captured in the Early
Learning Network (ELN). Programs may use this form to collect information from families or may use it to adapt current
program forms. Please capture the Child and Family Information in the fields provided below. Please use one form per
Child to collect this information.
Fields marked with an * are required.
Please note: This document contains sensitive personally identifiable information. Please handle / store this information
carefully.
Location Name:
Child Demographics Information
Last Name:* _____________________
MI: ____
First Name*: ___________________
Suffix: _____ (Jr., Sr., I, II, etc.)
Ethnicity:*
Hispanic
Non-Hispanic
Unknown
Race:*
(Select all that apply)
American Indian or Alaskan
Asian
Black or African American
White
Native Hawaiian or Pacific
Unknown
Other
Gender:*
Female
Male
Date of Birth:*
SSN Note: SSN is optional and is only used for the
Child’s Social Security Number: ______---_____---_______
Child Clearance process. Enter all 9 digits or leave
the field blank. If you do enter all 9 digits, only the
Programs this child is enrolled in this location: (Select all
last 5 digits will show in this field. All other digits will
that apply)
be masked.
Head Start State Supplemental Assistance Program
PA Pre-K Counts
School District Pre-K
Keystone STARS
Other
st
Is English the 1
language for the Child?:
Yes
No
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