Family Information Sheet printable pdf download

Family Information Sheet

Date: _____________

Family Information Sheet

Thank you for attending Imagination Station, a parent/child interactive

playgroup. We hope that you have a fun and safe time. Imagination Station is a

play at your own risk group.

/E&K

We would love if you could fill out this information sheet, so that we may better

serve all needs. This information also aids us in our grant requests. As a non-profit parent volunteer group we would

like you to let us know if you have any questions, concerns, would like to volunteer, or special needs. Thanks!

Names: (Parent & Child) _________________________________________________________

Address: ______________________________________________________________________

Phone #: ________________________________

E-Mail: _____________________________

EMERGENCY CONTACT: ______________________________________________________

EMERGENCY PHONE #: _______________________________________________________

I.S. is a 501(c)3, funded by your donations and grants that we apply for. Please consider filling out the OPTIONAL

information below, to help us with these efforts.

Check all that apply:

A) Children Ages Served:

Infant to 2 years

3 to 5 years

5 to 10 years

B) Adult Ages Served

18 to 35 years

35 years and

Please check if

above

you are pregnant

C) Ethnic Distribution:

Anglo

African American

Other

Hispanic

Asian

Family Information Sheet