Instructions Not Included

Congratulations on the birth of your child!

This is an exciting time that will also be filled with many questions, and as you will soon discover, your little bundle of joy did not come with an instruction manual. The Early Learning Institute’s Instructions Not Included program is here to assist you as you navigate your new role and help you build your personal instruction book.

Person Making the Referral

First Name

Last Name

Agency of Person Making the Referral

Phone Number of Person Making the Referral

(###)

###

####

Child Name

First Name

Last Name

Child's DOB

YYYY

Child's Ethnicity

Child Sex

Parent Name

First Name

Last Name

Parent DOB

YYYY

Parent Ethnicity

Parent Sex

Parent Language

Relationship to Child

Parent Name

First Name

Last Name

Parent DOB

YYYY

Parent Ethnicity

Parent Sex

Parent Language

Relationship to Child

Is This the First Child To At Least One Parent?

Yes

We have a Public Health Nurse or other agency that comes to our home on a regular basis

Yes

Family's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Phone Number

(###)

###

####

Cell Phone Number

(###)

###

####

Primary Language

Child's Doctor/Clinic

Health Insurance

Was this child premature?

Yes

If yes, how many weeks early?

Birth Hospital

Cal Fresh/SNAP

Yes