Welcome to the Follow Along Program Online Enrollment Form

Please complete the enrollment form below and click submit when finished. Only the starred * fields are required, however, any additional information you provide will help us connect you with other local early childhood resources you might be interested in.

The information collected on this form will be used to link you with the local public health staff in your county that provide the Follow Along Program. All of the information on this form is confidential and will only be used for Follow Along Program participation. If you have any questions, please contact the state program coordinator toll-free at 1-800-728-5420 or by e-mail at health.cyshn@state.mn.us.

Please note: The Follow Along Program is not currently available in the following counties. If you live in one of these counties and would like to be connected to other early childhood resources, please submit the enrollment form and the state program coordinator will contact you. Blue Earth, Mower, and Stearns.

Who is completing this form? *

Child/Family Primary Address (* signifies a required field)

Mailing Street *

Apt/Unit #

City *

Zip Code *

County *

Guardian Information (* signifies a required field)

Primary Guardian's First Name *

Primary Guardian's Last Name *

Secondary Guardian's First Name

Secondary Guardian's Last Name

Primary Phone *

Other Phone

Email Address (very helpful for program follow-up)

Primary Spoken Language *

Insurance (Check all that apply) *

Welcome to the Follow Along Program Online Enrollment Form

Child/Family Primary Address (* signifies a required field)

Guardian Information (* signifies a required field)

Child Information(* signifies a required field)