Child And Family Information Form Page 2
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3*Updated 06/24/2012*
ELN Data Fields Form
Child and Family Information
Please note: First, complete the Legal Guardian Information for the guardian who resides at the primary residence of the
child. All other guardians may also be entered. Copy pages as needed.
Legal Guardian Information
Last Name:*
First Name:*
MI:
Suffix:
(Jr., Sr., I, II, etc.)
Gender:*
Female
Male
Relationship to Child: *Per Act 24, this field is not required. Please select “Not Required”.
Father
Mother
Grandparent
Guardian
Other
Not Required
Secondary Relationship to Child: Per Act 24, this field is not required. Please select “Not Required”.
Biological
Foster
Adoptive
Step Parent
Other
Not Required
Role: Per Act 24, this field is not required. Please select “Not Required”.
Primary Guardian
Representative Payee
Secondary Guardian
Personal Guardianship
Legal Guardian
Substitute Decision Maker
Caregiver
Child Care Worker
Support Team Member
Case Worker
Power Of Attorney
Primary Care Physician
Living Will
Specialist
Fiscal Guardianship
Not Required
Address Line 1:*
Address Line 2:
City:*
State:*
Zip Code:*
County:*
School district of Residence:*
Check here if the School District of Residence is out of state.
Send Correspondence to this legal guardian
Primary address of the child
Phone:
Email:
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