"*" indicates required fields Child's Name* First Name Last Name Gender* Male Female Race* American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Multiracial Ethnicity* Hispanic/Latino MENA (Middle Eastern/North African) BOTH Hispanic/Latino and MENA NOT Hispanic/Latino and NOT MENA Unknown Ethnicity Date of Birth* Month Day Year This field is hidden when viewing the formAge in MonthsCreate Youth Account*Authorize this child to enroll in FACCES programming Yes No Youth UsernameYouth Email This child will receive an email to activate their account on the FACCES website.Currently Enrolled in Kindergarten*Is your child currently enrolled in Kindergarten? Yes Not yet Your Child's Health*Does this child have any special health concerns? Yes No Not sure Prefer not to answer Age GroupYour child’s current age group. Infant (0-18 mos.) Young Toddler (18 mos.-24mos.) Older Toddler (2-3 yrs.) Pre-K (3-5 yrs.) Kindergarten Age-Eligible Grades 1-5 Grades 6-8 Grades 9-12 FACCES Education Partner*Select the FACCES Education Partner or Program where your child is enrolled.Select Learning Center– Not EnrolledA Better Choice Daycare Learning CenterA Joyful Journey AcademyA. Sophie Rogers School for Early LearningAgora's Little GemsAll Saints AcademyCDCFCCDCFC – Linden ParkCentral Ohio ChildcareChosen Kids IIChosen Kids IIIClever Bee Academy (Cleveland Ave)Clever Bee Academy (Harrisburg Pike)Clever Bee Academy (Livingston)Clever Bee Academy (Northern Lights)Columbus City SchoolsColumbus Early Learning Centers – Alum CreekColumbus Early Learning Centers – Champion Ave.Columbus Early Learning Centers – Clarendon AveColumbus Early Learning Centers – Main StreetColumbus Early Learning Centers – Myrtle Ave.Columbus Early Learning Centers – SouthsideColumbus Montessori Education CenterConnected Pathways Early Learning Centers- EastonConnected Pathways Early Learning Centers- NorthlandCreative Child Care – EastCreative Child Care – NorthCreative Child Care – WestFresh Start Learning Academy IIIFuture Scholars Learning AcademyGladden Community HouseGoddard School – ReynoldsburgHeavenly Kids Center for LearningJoyful Beginnings Children's Learning AcademyKid's Care AcademyKiddie Academy-KIPPKiddie Academy-TussingKiddie KareLittle Disciples Learning CenterLittle Miracles EDCLittle Tigers Learning CenterMaize Manor PreschoolMary's Little Lamb Interactive Learning AcademyMichael's Lil AngelsMt. Carmel KindercareNationwide Children's Hospital (NCH) Primary CareOtherOur Kidz Enrichment CenterOur Learning & Enrichment CenterPrewitt’s Playhouse Early Learning CenterSchoenbaum Family Center at Weinland ParkSt. Mary Magdalene SchoolSt. Stephen's Community HouseStarting Point Learning CenterThe Childhood League CenterWashington Development and Learning CenterWoodland Christian CenterYMCA – ELC Johnstown RdYMCA – ELC WestYMCA – HilltopYMCA – Hilltop Early Learning CenterYMCA – NorthOther Program*Provide the name of the program where you child is enrolled.Qualify for Free or Reduced Lunch?*Does this child qualify for free or reduced school lunch? Yes No Not sure School Attended*Please list your child’s current school.Family Adult Name First Last This field is hidden when viewing the formEmail This field is hidden when viewing the formPhoneZipcode ZIP Code This field is hidden when viewing the formMember IDThis field is hidden when viewing the formMilestones CompletedThis field is hidden when viewing the formNew Goals Activity Plan CreatedThis field is hidden when viewing the formCore AreasThis field is hidden when viewing the formAreas of FocusThis field is hidden when viewing the formASQ Start DateThis field is hidden when viewing the formASQ SE Start DateThis field is hidden when viewing the formStarted ASQ Month Day Year This field is hidden when viewing the formASQ CompletedThis field is hidden when viewing the formASQ SE CompletedThis field is hidden when viewing the formASQ EnteredThis field is hidden when viewing the formAssignment #1 CompletedThis field is hidden when viewing the formAssignment #2 CompletedThis field is hidden when viewing the formAssignment #3 CompletedThis field is hidden when viewing the formAssignment #4 CompletedThis field is hidden when viewing the formKRA Scores UploadedThis field is hidden when viewing the formEnrolled in FACCES K Ready Ohio Yes This field is hidden when viewing the formProgram Email This field is hidden when viewing the formProgram Affiliation Early Start Columbus Other Early Start Columbus, CCB3 CCB3 None This field is hidden when viewing the formProgram Enrollment Date Month Day Year This field is hidden when viewing the formProgram Withdrawal Date Month Day Year This field is hidden when viewing the formCCB3 Enrolled Since Never enrolled in CCB3 Not enrolled in CCB3 Infant (0-18 mos.) Young Toddler (18 mos.-24mos.) Older Toddler (2-3 yrs.) Pre-K (3-5 yrs.) Kindergarten This field is hidden when viewing the formReport Access User Δ
