Child's Name *

First Name

Last Name

Child's date of birth *

MM

DD

YYYY

Race/Ethnicity

Please check all boxes boxes that apply. Nia House utilizes categories provided by the City of Berkeley. (Optional: Nia House does not discriminate on the basis of race, color, national origin, sex, religion, gender, sexual preference or ability.)

Native American

Filipino

Latino or Hispanic

Black or African American

White

Asian

Native Hawaiian or Pacific Islander

Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Name

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Start date *

MM

DD

YYYY