Connections Sign Up Child's InformationChild's First Name*Child's Middle Name*Child's Last Name*Date of Birth* Date Format: MM slash DD slash YYYY Birth Weight (lbs)Birth Weight (oz)SexMaleFemaleGestation WeeksRaceAfrican-AmericanAsian/Pac IslanderHispanicMulti-RacialNative AmericanWhiteOtherPediatricianPlease type your pediatrician's name hereChild's Medical HomePlease type your office name hereChild Care ProviderPlease type your child care provider name hereChild's Insurance TypePrivateMedicaidOtherNo InsurancePrimary Contact InformationFirst Name*Last Name*RelationshipBiological MotherBiological FatherAdoptive MotherAdoptive FatherGuardianFoster ParentRelativeOtherDate of Birth* Date Format: MM slash DD slash YYYY Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone*Email Marital StatusSingleMarriedDivorcedWidowedNumber of Members in Immediate FamilyRaceAfrican-AmericanAsian/Pac IslanderHispanicMulti-RacialNative AmericanWhiteOtherPrimary Care EducationElementary/Middle SchoolSome High SchoolHigh School or GEDTech SchoolSome CollegeAssociate DegreeBachelors DegreeMasters DegreeDoctorateAnnual Family Income$0 - $25,520$25,521 - $34,480$34,481 - $43,440$43,441 - $52,400$52,401 - $61,360$61,361 - $70,320$70,321 - $79,280$79,281 - $88,240More Than $88,240Biological Mother's InformationPlease skip if primary contact or unknown.First NameLast NameDate of Birth Date Format: MM slash DD slash YYYY Marital StatusSingleMarriedDivorcedWidowedNumber of Members in Immediate FamilyRaceAfrican-AmericanAsian/Pac IslanderHispanicMulti-RacialNative AmericanWhiteOtherMothers EducationElementary/Middle SchoolSome High SchoolHigh School or GEDTech SchoolSome CollegeAssociate DegreeBachelors DegreeMasters DegreeDoctorateAnnual Family Income$0 - $25,520$25,521 - $34,480$34,481 - $43,440$43,441 - $52,400$52,401 - $61,360$61,361 - $70,320$70,321 - $79,280$79,281 - $88,240More Than $88,240Biological Father's InformationPlease skip if primary contact or unknown.First NameLast NameDate of Birth Date Format: MM slash DD slash YYYY RaceAfrican-AmericanAsian/Pac IslanderHispanicMulti-RacialNative AmericanWhiteOtherEducation/Highest Grade CompletedElementary/Middle SchoolSome High SchoolHigh School or GEDTech SchoolSome CollegeAssociate DegreeBachelors DegreeMasters DegreeDoctorateOther InformationWhich language do you prefer for your questionnaire?EnglishSpanishHelp keep Connections' costs down by participating online:Both Questionnaire and ResultsOnly ResultsBy MailSchool district you live in:Allegan Public SchoolsAllendale PublicAlpena Public SchoolsAlpineAltoBaldwinBathBay City School DistrictBelding AreaBryon CenterByron Center PublicCaledoniaCaledonia CommunityCarson City-Crystal AreaCedar Springs PublicCentral MontcalmCharlotte Public SchoolsChesaningChicago Public SchoolsComstock Park PublicCoopersville Area PublicCrestonDearbornDewittEast Grand Rapids PublicEast LansingEdmoreForest Hills PublicFowlerFruitportGodfrey-Lee PublicGodwin Heights PublicGrand Haven AreaGrand Ledge PublicGrand Rapids PublicGrandville PublicGrant PublicGreenville PublicGull Lake Community SchoolsHamlinHartHaslettHastingsHolland PublicHopkins PublicHowellHudsonville PublicHundsonvilleHuron ValleyIonia PublicJenison PublicKelloggsville PublicKenowa Hills PublicKentKent City CommunityKentwoodKentwood PublicLakeview CommunityLakewood PublicLansingLowell AreaLudingtonLyonsManisteeMartin PublicMason CountyMCCMCEMiddlevilleMidland PublicMona Shores PublicMontabellaMontagueMontcalm Area IntermediateMuskegon PublicNewago PublicNorthview PublicOttawa Area IntermediateOttawa HillsPewamo-Westphalia CommunityPlainvillePortland PublicPottervilleReed CityReeths-PufferRockford PublicSaranac CommunityScottvilleShelbySibleySpartaSparta AreaSpring Lake PublicSpringfeildThornapple KelloggTri County AreaVestaburg Community SchoolsWalkervilleWaverlyWaylandWayland UnionWest Ottawa PublicWhite CloudWyomingWyoming PublicZeeland PublicUnlistedNot ListedCounty you live in:Where did you hear about Connections?MailingSocial MediaEventEmployerFamily Promise ReferralSpectrum Health: Baby Scholars ReferralWelcome Home BabyOtherI am interested in receiving additional information about home visit support services (for children 0-3 only).Yes!NoAdditional resourcesI would like additional assistance with:Please select any that apply: New Parent Resources Filling Out an ASQ Childcare Home Visiting Housing Finding a Doctor Food Pantries Transportation Employment Other Please let us know anything else you have questions aboutPermission to ParticipateI will let Connections use information about my child to test the success of their programs. I will let Connections share my ASQ survey results with their partners to build a stronger circle of support for my family. This includes health, mental health, child care, health department, or social services agencies. I will let Family Futures use my information for basic research. Connections will not print information that could identify my child in any public reports. This agreement does not have an end date. I can stop Connections from sharing my information at any time and for any reason by sending a written letter. Doing this will not change the services I get from Connections. Ready By Five ConsentThe Ready by Five Early Childhood Millage provides dedicated and sustainable funding for programs that improve the health, school readiness, and well-being of children under age five. It allows more children and families from across the community to participate in programs that are proven to increase their likelihood of success in school and beyond. Connections and its Navigation services are funded in part by the Kent County, voter-approved, Ready by Five Early Childhood Millage. By providing your signature below, you consent to the following sharing of your or your child’s personal information as described as follows. To best meet your and your child’s needs, Family Futures may be referring you to programs you are interested in. Family Futures will share individual information about you and your child only with programs that you have said you wish to receive services from. You are consenting to Family Futures updates on your and your child’s status of services from programs where you have accepted services. If in any follow-up phone calls or visits with a Family Futures representative, you wish to receive additional services that are not accepted on today's date of signed consent, you agree that Family Futures may make such referrals and exchange your information with the provider of the referred service based upon your verbal consent. Kent County’s Ready by Five Millage is providing the funding for services to expectant mothers and families with children through the age of five. As part of receiving Ready by Five Millage funding, Family Futures is required to collect specific data regarding the children and families served and services provided. This data will only be shared with your consent. The type of information that Family Futures will be collecting for Ready by Five Millage reporting includes: • Child name, birthdate, gender, race/ethnicity, address, and insurance type • Caregiver name, address, education, insurance type, marital status, employment status, household characteristics, household income and primary language spoken in the home • Information on the Connections services received such as date, location, type of service received, and satisfaction of services • Information on referrals to services and resources and if the family received requested service or resources • Information about expectant mother’s pregnancy and baby including due date and voluntarily self-reported health information about access to prenatal care, tobacco use, non-prescription drug use, breastfeeding, access to supplemental programs such as WIC, and concerns with post-partum wellbeing • Information voluntarily reported by the primary caretaker about the child including information such as status of child’s immunizations, involvement of welfare services (if applicable), child development screening, and information on related referrals (if applicable) You and your child’s information will be shared so it can be used for the purposes of community reporting, program quality improvement, and program evaluation. You and/or your child’s information will be shared with the Kent County Health Department. The Kent County Health Department will provide limited data about your child to The Kent Intermediate School District. You and your child’s information will be de-identified, meaning a child or parent will not be named in the data reports sent to First Steps Kent. All reports made publicly available to the community by Family Futures, Kent County Health Department and First Steps Kent will contain only de-identified information. This means that a child or parent will not be named and no reports will include any information that would allow people to determine your or your child’s identity or that you or your child received a millage-funded service. Information specifically about you or your child individually will not be shared without your expressed written consent. If you choose not to sign this consent, you are still able to receive Connections and Navigation services from Family Futures. You may cancel this consent form at any time by sending a cancellation request in writing to Family Futures at the following address: 678 Front Avenue NW Suite 210, Grand Rapids, Michigan 49504. A more specific description of how your information will be shared and used for the purposes of Ready by Five Early Childhood Millage can be found as part of the Ready by Five Privacy Notice on the First Steps Kent website at www.firststepskent.org/readybyfiveprivacy. Ready by Five Early Childhood Millage proporciona fondos dedicados y sostenibles para programas que mejoran la salud, la preparación escolar y el bienestar de los niños menores de cinco años. Permite que más niños y familias de toda la comunidad participen en programas que han demostrado aumentar su probabilidad de éxito en la escuela y más allá. Connections y sus servicios de navegación son financiados en parte por el Condado de Kent, aprobado por los votantes, Ready by Five Early Childhood Millage. Al proporcionar su firma a continuación, usted acepta compartir la siguiente información personal suya o la de su hijo/a como se describe a continuación. Para mejor satisfacer las necesidades de usted y las de su hijo/a, Family Futures puede referirle a los programas que más le interesan. Family Futures compartirá la información individual sobre usted y su hijo/a sólo con los programas que usted indicó desear recibir información. Usted está dando su consentimiento a Family Futures para recibir actualizaciones sobre su estado y el de su hijo/a de los programas que aceptó sus servicios. Si en alguna llamada telefónica de seguimiento o visita con un representante de Family Futures desea recibir servicios adicionales que no han sido aceptados en la fecha de consentimiento firmado hoy, usted acepta que Family Futures pueda referirle e intercambiar su información con el servicio del proveedor referido, basado en su consentimiento oral. Kent County Ready by Five Millage, proporciona los fondos para los servicios a mujeres embarazadas y a familias con hijos/as hasta los cinco años de edad. Como parte de recibir financiación a través de Ready by Five Millage, Family Futures debe recopilar datos específicos sobre los hijos/as y las familias atendidas y de los servicios ofrecidos. Estos datos sólo se compartirán con su consentimiento. El tipo de información que Family Futures recopilará para los informes de Ready by Five Millage incluye: • Nombre del niño, fecha de nacimiento, sexo, raza, dirección y clase de seguro médico. • Nombre del cuidador, dirección, educación, tipo de seguro médico, estado civil, estado laboral, características del hogar, ingresos e idioma que se habla en el hogar. • Información sobre servicios de Connections recibidos, como la fecha, ubicación, tipo de servicio y la satisfacción de los servicios. • Información sobre referencias a servicios y recursos y si la familia recibió los servicios o recursos solicitados. • Información sobre el embarazo de futuras madres y bebés, incluida la fecha de parto y la información voluntaria de la salud sobre el acceso a la atención prenatal, el consumo de tabaco, el uso de medicamentos sin receta, la lactancia materna, acceso a programas complementarios como WIC y preocupaciones sobre el bienestar del posparto. • Información comunicada voluntariamente por el cuidador principal sobre el niño, incluyendo información sobre preocupaciones relacionadas con el entorno del hogar, como el aumento del nivel de plomo en la sangre, la confirmación de detección de plomo, riesgos de asma identificados e información sobre referencias relacionadas (Si corresponde) La información de usted y la de su hijo/a será compartida para que pueda usarse con fines comunitarios, calidad del programa y evaluación del programa. La información de usted y/o la de su hijo/a será compartida con el Departamento de Salud del Condado de Kent. El Departamento de Salud del Condado de Kent, proporcionará datos limitados sobre su hijo a Kent Intermediate School District. La información de usted y la de su hijo/a será des-identificada, lo que significa que un niño o un padre no será nombrado en los informes de datos enviados a First Steps Kent. Todos los informes puestos a disposición de la comunidad por (Proveedor de Servicios), al Departamento de Salud del Condado de Kent y a First Steps Kent, contendrán sólo información des-identificada. Esto significa que un niño o los padres no serán nombrados y ningún informe incluirá información que permita a las personas determinar su identidad o la de su hijo/a o que usted o su hijo/a recibieron un servicio financiado por este impuesto (millage). La información específica sobre usted y su hijo/a individualmente no se compartirá sin su consentimiento por escrito. Si elige no firmar este consentimiento, aún puede recibir los servicios de Connections y Navegación de Family Futures. Puede cancelar este formulario de consentimiento en cualquier momento enviando una solicitud de cancelación por escrito a Family Futures a la siguiente dirección: 678 Front Avenue NW Suite 210, Grand Rapids, Michigan 49504. Se puede encontrar una descripción más específica de cómo se compartirá y utilizará su información para los fines de Ready by Five Early Childhood Millage como parte del aviso de privacidad de Ready by Five en la web de First Steps Kent. PLEASE SIGN BY TYPING YOUR FULL NAMEI do not want Family Futures to use my family’s information for research purposes, but I still want to participate in Connections.YesNoNameThis field is for validation purposes and should be left unchanged.
