Pre intake Form

Name *

First

Last

Street Address *

Town, State, Zip Code *

Phone Number *

Email *

Child’s Name *

Child’s Date of Birth *

Name of Employer *

Is the Child's Primary Caregiver Currently Enrolled in School? *

Name of School

Participating in Job First Program? *

Job Hunting *

Combined Household Income: Check One *

Family Size *

The Riverfront Children’s Center, Inc.

476 Thames Street, Groton, CT 06340

Monday – Friday: 6AM – 5PM
Saturday & Sunday: Closed

PHONE: 860-445-8151
FAX: 860-445-4099