CHILD INTAKE INFORMATION                                                    (attach photo of child)    Child:_________________________________________M:______ F:______                            (complete separate sheet for each child)    DOB: ____/____/____                Age: ______                SS#: _____/_____/_____        Height: ______    Weight: _____    Hair Color: ______        Eye Color: ______    Distinguishing traits: ______________________________________________    Race/National Origin: White___Black___Hispanic___Native American___                                          Asian/Pacific Islander___Unknown___Other___    Special needs:____________________________________________________    _________________________________________________________________    School: ___________________________School District: _________________    How long has it been since child has seen other party? ________________    Possible reactions to seeing other party: _____________________________    _________________________________________________________________    Allergies, medication, etc. That other party should be aware of: __________    _________________________________________________________________    Comments: _______________________________________________________    _________________________________________________________________    _________________________________________________________________