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Medicaid #:Easter Seals PCI Program Prior Written Notice and Consent Screening Assessment Evaluation Child's Name Date of BirthClient IDDateUnder 34 CFR 303.421, the PCI program must give you a written
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To fill out the child's name and date of birth, follow these steps:
02
Find the section on the form that asks for the child's information.
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Write the child's full name in the designated space.
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Enter the child's date of birth in the specified format, usually month/day/year.
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Double-check the accuracy of the provided information.
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If you are filling out an online form, click on the 'Submit' button to save the details.
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If you are filling out a paper form, review it once again for any errors before submitting it.

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Parents or legal guardians typically need the child's name and date of birth when filling out various forms, such as:
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- Birth certificate applications
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- School enrollment forms
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- Health insurance paperwork
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- Passport applications
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- Legal documents regarding custody or guardianship
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- Financial or tax-related forms for child-related benefits
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