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Crossroads – CTad – Infant New Family/Family Demographics Screen (fill-out once for entire family) Parent/Guardian1 Participant Last Name: __________________________________________First Name: __________________________________M.I. ________

Proof of Identification: ___________________________________SSN: _____________________________DOB: ________________

Marital Status: ____________________________________Education Level: _____________________________________________ Parent/Guardian2 Last Name: __________________________________________First Name: __________________________________M.I. ________

Proof of Identification: ___________________________________SSN: _____________________________DOB: ________________

Marital Status: _____________________________________Education Level: ____________________________________________ Caretaker Last Name: __________________________________________First Name: __________________________________M.I. ________

Proof of Identification: ___________________________________SSN: ______________________________DOB: _______________

Marital Status: _______________________________________Education Level: ___________________________________________ Physical Address: Street: ______________________________________________________________________________________________________

Street 2: ____________________________________________________________________________________________________

ZIP: _______________________City: __________________________________State: _______County: ________________________

Proof of Residence: ___________________________________________________________________________________________

Homeless/Incarcerated Status: _____________________________________Migrant Status: ________________________________ Mailing Address: Street: ______________________________________________________________________________________________________

Street 2: ____________________________________________________________________________________________________

ZIP: _______________________City: __________________________________State: _______County: ________________________

Telephones:

Voter Registration: Telephone Number: __________________ Type: H, C, W, F, M Primary: _______ Carrier: _______________________ Telephone Number: __________________ Type: H, C, W, F, M Primary: _______ Carrier: _______________________ Military Status – Non-military, National Guard, Active

Confidentiality:

Communication Options: Language Read: ________________Language Spoken: __________________ Interpreter Sign Language Interpreter

Email Address: _____________________________________Preferred Method of Contact: ________________________________

Family Assessment Screen (fill-out once for entire family) 1. Does anyone smoke inside your house?

Yes

No 2. Has adequate household food storage and preparation? Yes

No 3. Has household food insecurity?

Yes

No 4. Source of drinking water? City Not Sure Well Cistern Spring Other 5. Where did you hear about WIC? ________________________________________

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