Little Learners’ @Home Kit – December

Child's full name: *

Child's age: * 2 3 4 5

Parent/guardian's full name: *

Email: *

Phone: *

Does participant have any allergies? (if yes, please list): *

Are you enrolled in the Idaho State Infant and Toddler Program?: Yes No

For grant reporting purposes, please indicate the child's ethnicity (optional): American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White/Caucasian Other (Specify below)

Other (specify):

Mailing Address to send kits to:: *

City: *

State: *

Zip Code: *

Terms and conditions (see link below): * I agree