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Help Me Grow SolanoWe are very excited that you have decided to work with Help Me Grow Solano to ensure your child gets off to the best possible start in life. There are two ways to connect to services:

1. Complete all required information below on this page and press “submit.”

2. Dial 844-501-KIDS (5437) and tell the Intake Coordinator that you would like to connect to Help Me Grow

CONNECTION FORM

CONNECTING PARTY

NAME: AGENCY (if applicable): Date:
PHONE: EMAIL:
PLEASE TELL US HOW YOU HEARD ABOUT HELP ME GROW SOLANO:

CLIENT INFORMATION

CHILD'S NAME: DOB (or due date): GENDER:
PARENT/CAREGIVER NAME/S: DOB: RELATIONSHIP TO CHILD:
ADDRESS:
CITY: STATE: ZIP:
PRIMARY LANGUAGE OF CAREGIVER / LANGUAGE SPOKEN IN HOME: ETHNICITY:
INSURANCE:YesNo

WHAT TYPE OF INSURANCE?:
PHONE: ALTERNATE PHONE:
EMAIL:

REQUESTED SERVICES (select one or more services)

REASON FOR CONNECTION / COMMENTS

Please Enter Your Contact Email Here (required)

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