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1365 S. Waterman Ave San Bernardino, CA 92408

Early Start Online Application

Child's Full Name

Sex

Family Primary Language

Child Date of Birth

Date Picker

Basic Information

Is the child in foster care?

Parent Name

Parent Name

Foster Parent Name

Foster Parent Name

Physical Address

    Mailing Address (if different from physical address)

      Do you live in:

      Referral Information

      What are the developmental concerns you have for your child?

      How did you hear about our program?

      Completed By:

      For Official Use Only:

      Chronological Age:

      45 Day Timeline:

      Inquiry:

      UCI: 

      Vendor:

      School District: 

      Service Coordinator: 

      Additional Notes: