“We accept funds from the New York State Department of Social Services.” NYSDSS Interview Form Child's Full Name(Required) Date of Birth MM slash DD slash YYYY Home Address(Required) Home Phone NumberMother's Name(Required) My Child Calls Me Cell Phone NumberEmail Address(Required) Occupation Work Address Work Phone Number(Required)Father's Name(Required) My Child Calls Me Cell Phone NumberEmail Address(Required) Occupation Work Address Work Phone Number(Required)Sibling AgeParents Marital Status Does the child live with both natural parents?YesNoEmergency Contact Information Name Phone NumberRelation to Child Pediatrician Address Phone NumberAllergies About Your ChildFor snack my child likes to eat: For lunch my child likes to eat: My child loves to: When child is upset, what calms him/her down? Language(s) spoken at home: Language(s) spoken by child: How does your child respond to new situations: Any other information you would like us to know about your child: How did you hear about our Preschool? CAPTCHANameThis field is for validation purposes and should be left unchanged.
