Black EarlyON Intake form

Black EarlyON Intake form

Note to the client: Every client must complete a registration form to access DFRC services. Collected information is protected by the Privacy legislation and it is used to meet reporting requirements for funding.


Client Information


Child's Information


Photo consent


Consent to Collect, Use, and Disclose Information

Delta Family needs to collect personal information to provide the best services that meet clients’ needs and eligibility criteria, and for reporting purposes without naming individuals. Information that might be shared with funders and for reporting purposes are related to demographics, nature of needs addressed, and number of services provided.  Personal information collected, including your name, contact information, specific needs, documentation related to services, and outcomes is strictly private and confidential.

You understand that your personal information (name and contact information as well as service requested) might be shared internally with different programs if you have identified various needs and requested different services from the list described above.


Second Child's Information


Emergency Contact


Emergency Procedure


Release Authorization

Child(ren) attending DFRC programs will not be released to anyone but the parent/guardian unless authorized.


Third Child's Information


Fourth Child's Information