Connections Sign Up Child's InformationChild's First Name*Child's Middle Name*Child's Last Name*Date of Birth* 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 NameLast NameRelationshipBiological MotherBiological FatherAdoptive MotherAdoptive FatherGuardianFoster ParentRelativeOtherDate of Birth Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country PhoneEmail 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 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 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 free 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?Welcome Home BabyMailingEmployerOtherI 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.
