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 IncomeLess than $5,000$5,000-$9,999$10,000-$14,999$15,000-$19,999$20,000-$24,999$25,000-$29,999$30,000-$39,999$40,000-$49,999$50,000-$74,999$75,000-$99,999$100,000 or moreBiological 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 IncomeLess than $5,000$5,000-$9,999$10,000-$14,999$15,000-$19,999$20,000-$24,999$25,000-$29,999$30,000-$39,999$40,000-$49,999$50,000-$74,999$75,000-$99,999$100,000 or moreBiological 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 MediaEmployerSpectrum Health: Baby Scholars ReferralWelcome Home BabyEventOtherI am interested in receiving additional information about home visit support services (for children 0-3 only).Yes!NoPermission 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. 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.YesNoCommentsThis field is for validation purposes and should be left unchanged.
