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Referral Form

Infant Toddler Services of Kansas Serving Pottawatomie & Wabaunsee Counties

Please fill out this online referral form to begin the referral process.

*Referral Date

*Person making the referral:

I am a parent/guardian making a referral for my child.

I am a community partner making a referral for a child.

Name of Person Making Referral

Referral Source Email

*Reason for the Referral

CHILD INFORMATION

*Child's Date of Birth

Día

Mes

Año

*Child's First Name

Child's Middle Name

*Child's Last Name

*Child's Gender

Male

Female

*Child's Home Address

Where is the child during the day?

Home

Daycare

Other

*Primary Language Spoken in the Child's Home

*Child's Race

Alaska Native/American Indian

Asian

Black

Native Hawaiian/Pacific Islander

White

Hispanic

GUARDIAN INFORMATION

*Parent/Guardian Full Name

*Parent/Guardian Address

*Parent/Guardian's Phone

May we text this number?

Yes

No

Parent Email

Is there a 2nd parent with custody of the child?

Yes

No

2nd Parent/Guardian Full Name

2nd Parent/Guardian Address

2nd Parent/Guardian's Phone

May we text this number?

Yes

No

2nd Parent Email

Is this child in foster care?

Yes

No

MEDICAL INFORMATION

Child's Pediatrician

Name of Child's Insurance, Insurance Number NOT Required

Child's Medicaid ID # (if applicable)

Please upload an image of the child's medical ID card (if available).

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