ParentChild+ sign up- ages 2-3 years old

Please complete this application if you can answer yes to the following three questions.

1. Is your child between 2 and 3 years old?

2. Do you live in Georgetown County, SC?

3. Can you or a caregiver commit to 2 weekly 30-minute home visits with you and your child?

All of your information is confidential, and we DO NOT share your information with anyone.

If your child is under 2, sign up for our waiting list on our website.

Your Contact Information

First Name *

Last Name *

Email *

Address Line 1 *

Address Line 2

Phone *

City *

State *

Zip *

Your mailing address if different than above The maximum length for the field Your mailing address if different than above is 500 characters.

How do you prefer we contact you, call or email? The maximum length for the field How do you prefer we contact you, call or email? is 500 characters.

Do you need a bi-lingual home visitor? The maximum length for the field Do you need a bi-lingual home visitor? is 500 characters.

Child's full name The maximum length for the field Child's full name is 500 characters.

Child's date of birth The maximum length for the field Child's date of birth is 500 characters.

How did you hear about us? The maximum length for the field How did you hear about us? is 500 characters.

How do you prefer we contact you, call or email? The maximum length for the field How do you prefer we contact you, call or email? is 500 characters.