Santa Maria, Lompoc, Nipomo, Guadalupe, Buellton, Santa Ynez, Los Alamos, or Chumash Reservation (18) Connect with Intake Coordinator - Santa Barbara - Under 3 (Web_Intake_ES_North) Today's Date(Required) Child's Name(Required) Date Of Birth (DOB) Child's age(Required) Gender Parent or Guardian(Required) Maiden Name Additional Parent or Guardian Parental Consent to Referal? (Yes or No)(Required) Parents Live Together? (Yes or No) Custody Court Documents On File? (Yes or No) Preferred Language? Interpreter Required? (Yes or No) ZIP Code(Required) Mailing / Home Address (As much information as available)Telephone of the Contact Person (and name if different than Guardian)(Required) Email of the Contact Person Best Way to Contact Issues / Comments Everywhere Else in SB County (25) Connect with Intake Coordinator - Santa Barbara - Under 3 (Web_Intake_ES_SB_South) Today's Date(Required) Child's Name(Required) Date Of Birth (DOB) Child's age(Required) Gender Parent or Guardian(Required) Maiden Name Additional Parent or Guardian Parental Consent to Referal? (Yes or No)(Required) Parents Live Together? (Yes or No) Custody Court Documents On File? (Yes or No) Preferred Language? Interpreter Required? (Yes or No) ZIP Code(Required) Mailing / Home Address (As much information as available)Telephone of the Contact Person (and name if different than Guardian)(Required) Email of the Contact Person Best Way to Contact Issues / Comments
