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Follow Along Program Online Enrollment Form (FAP)

  1. A drawing of a baby chick, the symbol of the Chick Follow Along Program
  2. Follow Along Program Online Enrollment Form
  3. If not the parent/guardian, please consent:

    I confirm that I have shared information about the Follow Along Program with the parent/guardian and have received verbal or written permission from the parent/guardian to submit a Follow Along Program enrollment form for this child on their behalf. If you don't have permission to submit this enrollment, you may cancel it by closing the webpage. Please provide the family the Follow Along Program website to complete their own enrollment: https://www.co.sherburne.mn.us/406/Follow-Along-Program

  4. Child/Family Primary Address
  5. Guardian Information
  6. Interpreter Needed?
  7. Insurance (Check all that apply)*
  8. Child Information
  9. Child's Gender*
  10. Hispanic or Latino*
  11. Race/Ethnicity (check all that apply)*
  12. Was child born prematurely (before 37 weeks gestation)*
  13. Were there any pregnancy concerns? *
  14. Was the child in the NICU (Neonatal Intensive Care Unit)?*
  15. Does this child have any health conditions or diagnosis?*
  16. At birth, was the child's hearing tested in the hospital? *
  17. Were there any hearing concerns? *
  18. Do you have any concerns about the child's development? *
  19. How did you hear about the Follow Along Program? (check all that apply)
  20. Electronic Signature Agreement*

    As the parent/guardian of the child I am enrolling through the on-line Follow Along Program form, I have read the Follow Along Program Permission Form and I agree to the conditions of the program by checking the box below.

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    If I do not agree to the conditions of the program, I can close this webpage and none of my information will be saved or submitted. Contact the program coordinator toll free 1-800-728-5420 or email at health.cyshn@state.mn.us with any questions.

  21. Leave This Blank:

  22. This field is not part of the form submission.