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Custody
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Race
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White
Hispanic
Yes
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English Proficiency
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Moderate
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Other Language
African Language
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English
French
German
Gujarati
Japanese
Mandarin
Nepali
Portugese
Spanish
Other Language Proficiency
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Moderate
None
Proficient
Highest Grade Completed
Associate's Degree
Bachelor's Degree
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College or Advance Training
General Education Diploma
Grade 10
Grade 11
Grade 12
Grade 9 or less
High School Graduate
Master's Degree
Employment Status
Full-time & Training
Full-time (35 hours/week or more)
Part-time & Training
Part-time (Under 35 hours/week)
Retired or Disabled
Seasonally Employed
Training or School
Unemployed
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Lives with Family
Yes
No
Provides Financial Support
Yes
No
Teen Parent
Yes
No
Family Information
Number of Parents/Guardians
One Parent Family
Two Parent Family
Relationship to Participant(s)
Foster parent(s) not including relatives
Grandparent(s)
Other
Parent(s) (e.g. biological, adoptive, stepparents)
Relative(s) other than grandparents
Primary Language at Home
African Language
American Sign Language
English
French
German
Gujarati
Japanese
Mandarin
Nepali
Portugese
Spanish
Number in Family
Gross Annual Income
Is your family receiving cash benefits or other services under the Temporary Assistance for Needy Families (TANF) program?
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No
Is your family receiving Supplemental Security Income (SSI)?
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No
Is your family receiving services from WIC?
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No
Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps?
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Is at least one parent/guardian an active duty member of the United States military?
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Is at least one parent/guardian a veteran of the United States military?
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Emergency Contacts
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Child (Applicant)
First Name (Required)
Middle Name
Last Name (Required)
Suffix
Nickname
Birthday (Required)
Gender
Female
Male
Race
American Indian or Alaska Native
Asian
Black or African American
Hispanic/Latino
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic
Yes
No
English Proficiency
Little
Moderate
None
Proficient
Other Language
African Language
American Sign Language
English
French
German
Gujarati
Japanese
Mandarin
Nepali
Portugese
Spanish
Other Language Proficiency
Little
Moderate
None
Proficient
Primary Health Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Insurance Number
Doctor/Medical Home
ABC Pediatric Group
ABC PEDIATRICS
ABOLHASSAN YAMIN
ALAN CU CHIAM, MD
ALEXANDER FAMILY DENTISTRY
AMAZING PEDIATRICS
AMINA PEDIATRICS
ANGELA JACKSON MD
ANNIE VARGHESE
ASA G YANCY HEALTH CENTER
ATLANTA PEDIATRIC PARTNERS
Augusta Pediatric Associates
BAYBOL PEDIATRICS LLC
BEATRICE FILES
BRIARCLIFF PEDIATRICS
BROOKHAVEN HEALTH CENTER
BYRON COTTON
C. CHARLES-MAY
Camp Creek Comprehensive Care
CAMP CREEK PEDIATRICS
CAPN INC.
CENTER FOR BLACK WOMENS WELLNESS
CENTER FOR HEALTH AND REHABILITA
CHILDREN'S HEALCARE OF ATLANTA
CHILDREN'S MEDICAL CENTER
Children's medicine
CHILDREN'S MEDICINE P.C.
Childrens Care Pediatrics
CHILDRENS MEDICAL GROUP
CHOA - Scottish Rite
CJ PEDIATRICS
Clara's Healthcare
CLAYTON CO. HEALTH DEPT.
Clinica Union
CLINICA UNION
Cobb & Douglas Public Health
COBB PEDIACTRICS ASSOCIATES
Cobb Pediatric Associates
Community Advanced Practice
Comprehensive Family Healthcare
CONSULTORIO MEDICO HISPANO
Consultorio Medico Hispano
CONYERS PEDIATRICS
COOPER PEDIATRICS
Covenant Care Pediatrics
Covington Family Care
COX, MARY MD
Crescent Pediatrics
Crosslinks Family Practice LLC
Cumberland Pediatrics
Cumming Pediatric Group
CYNTHIA KELLY MD
Dacula Pediatrics
DAFFODIL PEDIATRICS
Daffodil Pediatrics - Tucker
DAFFODIL PEDIATRICS AND FAMILY M
DANITA STEWART
DAVID WAEL HAMMAD M.D.
Dawson Pediatric
DECATUR PEDIATRIC GROUP
DeKalb County School District
DEKALB PEDIATRICS
Dekisha Drayton, MD
Delta Pediatrics
Denetra Robinson, RN
DOUGLAS PEDIATRICS, ASSOCIATES
Dr. Goza
E. Gotlieb
EAGLES LANDING PEDIATRIC ASS
East Cobb Pediatrics
EAST POINT PEDIATRICS/GRADY
EAST SIDE PEDIATRICS
Emory at Dunwoody
Emory Nurses
Eric Hoffler, MD
EVE MASCLINOT
EVE WEXLER, MD
Family Care Clinic
FAMILY HEALTH CENTER OF GA
Family WellnessMD
FAMILYCARE MEDICAL
Fayne Therapy
First GA Physician Group
First Lithonia Medical Center
Four Corners Primare Care
Fulton County Dept of Health
GC Duluth Pediatrics
Georgia Family Care
Georgia Highlands Medical Servic
GEORGIA UROLOGY
Gerald Lee, MD
GLORIA SMILDE
Good Samaritan Health Center
Grady East Point
GRADY MEMORIAL HOSPITAL
Grady Pediatrics
Greater Atlanta Pediatrics
Gwinnett County Public School
Gwinnett Pediatrics & Adolescent
Hamilton Mill Pediatrics
Harry Foster Jr.
HEALTHY STAGES PEDIATRICS
Healthy Steps Pediatrics
HELENA K BENTLEY M.D.
Henry County Pediatrics
HERRON PEDIATRICS
HUGES SPALDING/CHOA
INMAN PARK PHYSICIANS
International Pediatric Clinics
INTOWN PEDIATRIC & ADOLESCENT ME
IVY LEAGUE PEDIATRICS
James Gleason Jr
JAQUELIN GOTLIEB
Jennifer Massey
JENNIFER SHU
JENNIFER WING
JESSIE BRITUS
Jesup Pediatrics
JONESBORO PEDIATRICS
JOSEPHINE DUNAGAN
Juan Sherwood
KAISER CONYERS
Kaiser Pemanente
KAISER PERMANENTE
KAISER PERMANENTE
Kaiser Permanente Douglasville
Kaiser Permanente Cumberland
KAISER-CASCADE
KAISER-PERMANENTE
KAISER-SOUTHWOOD
Kecia Jackson
KEILA BROWN
KID CARE PEDIATRICS
KIDS & TEENS PRIMARY HEALTHCRE
Kids Avenue Pediatrics
KIDS CHOICE PEDIATRICS
Kids Clinic
Kids Doc Pediatrics
KIDS FIRST PEDIATRIC GROUP
KIDS WORLD PEDIATRIC
Kidscare Pediatric
Kidz Therapy Networks
KIM, JENNY MD
Kimberly Bates MD
KIRKWOOD HEALTH CENTER
L.HUYN
La Clinica del Niño
La Vista Norcross Clinic
Latin American Medical Center
LAWRENCEVILLE HEALTH CENTER
Lawrenceville Pediatrics
Lets Talk Therapy
LIFE CYCLE PEDIATRICS EAST POINT
Lilburn Pediatrics
LINDA WADE
LONGSTREET CLINIC
M.O Tomh M.D
Magnolia Pediatric
MAIN STREET INTERNAL MEDICINE
MAMATHA GAVINI
Marc Kolender
MARIA BATLLE
MARIA ROSSO
MARIBEL ANGKA-SEVERA
Mason Children's Associates
MASON PEDIATRICS
McDonough Pediatrics P.C.
MD RAJAMANI IYER PARKWAY MEDICAL
MedCura Health Inc
Medilag Pediatric
Medlink Gainesville
MEDLOCK PEDIATRIC
Megan Byrnes
MELINDA AMOSU
Melinda Willingham
Mercy Care Chamblee
MILDSTONE PEDIATRICS
MILES & LIB CHILDRENS CLINIC
Millcreek Pediatrics
MOREHOUSE MEDICAL ASSOCIATES
MUHAMMAD ALI
NATHANIEL WILSON, PSY.D.
NEVORN ASKARI, MD
NICOLA CHIN
NINO RENZO FORNASINI
North Atlanta Ear, Nose & Throat
North Fulton Health Center
NORTH FULTON PEDIATRICS
North Georgia Pediatric Dentistr
Northeast Atlanta ENT
Northeast Geoorgia Physician Gro
NORTHLAKE PEDIATRICS
Norwood Pediatrics
NUESTROS NIÑOS/OUR KIDS PEDIATRI
OAKHURST MEDICAL CENTERS INC
OLD FOURTH WARD
Old Fourth Ward Pediatrics
Omega Pediatrics
Oscar Medical Center
PAL Pediatric
Parikh Yashaswini
Peach State Pediatrics
Peachtree Park Pediatrics
Pedaitric Health of Dunwoody
PEDIA DOC CHILDREN'S MEDICAL
Pediatric & Adolescent Clinic
Pediatric Asociates Of L'ville
Pediatric Center of Stone Mounta
Pediatric Ear Nose&Throat ATL
PEDIATRIC HEALTH CENTER
PEDIATRIC PARTNERS OF GWI
Pediatric Partners of Gwinnett
PEDIATRIX NEWBORN
PLEASANT PEDS CARE OF CONYERS
POTTS PEDIATRIC& ADOLESCENT MED
PREMIER PEDIATRIC ASSOCIATES
Primary Pediatrics
PRINCETON LAKES PEDIATRICS
Pro Diagnostics
R. PLATNER
R.CHAUDHARI, MD
RODNEY KREIDER MD
S. P. REDDY
Sage Hill Pediatrics
SANDY PLAINS PEDIATRICS
SANDY SPRINGS PEDIATRICS
SEKHAR SANKARAN
SHAH PEDIATRICS
SHARMILA THADANI
SHARON CAMPBLL DNP
Shaveanda Queen
SHELLY-ANN SALANDY
SHINTE LIU
SIBLEY HEART CENTER
SMYRNA PEDIATRICS
SNAPFINGER WOODS PEDIATRICS
SNELLVILLE PEDIATRICS
SONYA BONNICK
SOUTH ATLANTA PEDIATRICS
SOUTHERN CRESCENT PEDIATRICS
SOUTHSIDE MEDICAL CENTER
SOUTHSIDE MEDICAL CENTER
SOUTHSIDE PEDIATRICS
ST JOSEPHS PEDIATRICS
STAHLMAN, JON MD
Star Family Healthcare/Wellness
Stay Well Pediatrics
Stephen Lookadoo
STOCKBRIDGE PEDIATRICS
Strickland Family Medicine Cente
SUGARLOAF PEDIATRICS
SULTON PEDIATRIC GROUP
Sunflower Pediatric
Sunflower Pediatrics LLC
SUWANEE PEDIATRICS
T O VINSON HEALTH CENTER
T. MORTON-ACKEN
Tara Lane
TeamCare
TeamCare
TEENS LITTLE ONES & CHILDREN
TENDER CARE PEDIATRICS
THE FAMILY HEALTH CENTER
The Kids Specialist
THE PEDIATRIC CENTER OF STN MTN
TLC PEDIATRICS, LLC
TONYA LIGGION, MD
TREE OF LIFE HEALTH ALLIANCE
TRI-COUNTY PEDIATRICS
TRUDDIE E. DARDEN
TWINKLE PEDIATRICS
TYSHANTRA COLEMAN
UNITED PEDIATRICS
VALARIE MANLEY WRIGHT MD
Valentine Pediatric Group, LLC
VALERIE BENJAMIN MD
VERRAS PEDIATRICS
W. HAMMAD
WALTER PALOMO MD
WE CARE PEDIATRICS GROUP
WELLSTAR KENNESTONE PEDIATRICS
WELLSTAR ROSWELL ROAD
WELLSTAR SOUTH COBB
Wellstart Medical- Pediatric Hos
WEST END MEDICAL CENTER
Westside Pediatrics
WHITEFOORD INC. MEDICAL CENTER
WIC
YVONNE L. SMITH
ZAMAN PEDIATRICS CENTER
Dental Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Dentist/Dental Home
A Dental Home for Kidz Fayettevi
A SMILE 4 U
A-Z DENTAL
Afshan Bintory
ALEXANDER FAMILY DENTISTRY
APPLE TREE PEDIACTRIC DENTISTRY
Atlanta Pediatric Dental
BEAUTIFUL SMILES MLK
BEAUTIFUL SMILES OF COLLEGE PARK
BELLA DENTAL SERVICES
BEST CARE DENTAL
Bingham Dental Group LLC
BLUSH DENTAL STUDIO
BRIGHT SMILES/COLGATE VAN
BRIGHTEN YOUR SMILE
Brittany Walker, DMD
CAMP CREEK PEDIATRICS
CAMP, LANESHIA DDS
CANDLER DENTAL ASSOCIATES
CANDLER ROAD DENTAL PC
Center for Pediatric Dental Seda
CENTER OF REFUGE
Central Dekalb Health Center
CHILDREN & TEEN DENTAL
CHILDREN'S DENTISTRY AT STONECRE
CHILDREN'S DENTISTRY OF LAWRENCE
Childrens Dentistry
CHILDRENS HEALTHCARE OF ATLANTA
CHRISTY HAFFNER
CLAYTON CO. HEALTH DEPT.
CLAYTON STATE DENTAL HYGIENE
COLGATE DENTAL VAN
Community Advanced Practice
COSMETIC AND GENERAL DENTISTRY
COSMO DENTIST
Crawford Orthodontic Care
D4C Sandy Springs
DAFFODIL PEDIATRICS
DAI MINH LE NGUYEN
Dana Harris-Echols
DAVID REZNIK, DDS
Delores Hubbard, DDS
Dental Now 14
Dental Now Kids
Dental Professionals Of Vinings
Dentistry 4 Children-Peachtree C
Dentistry 4 Kids-Suwanee
Dentistry for Children- Morrow
Dentistry For Children-Atlanta
Dentistry For Children-Buford
Dentistry For Children-Duluth
Dentistry For Children-Dunwoody
Dentistry For Children-Jonesboro
Dentistry For Children-Marietta
Dentistry For Children-Sandy
Dentistry For Children-Snellvill
Dentistry For Children-Stockbrig
Dentistry For Children-Stone M
Dentistry For Children-Suwanee
Dentistry For Children-Woodstock
Dentisty For Children-Smyrna
Douglasville Dentistry for Kids
Dr. Goza
EAST ATLANTA PEDIATRIC DENTISTRY
East Cobb Dentistry for Kids
EATON PEDIATRIC DENTISTRY
ENT OF GEORGIA
FABULOUS SMILES
FAMILY AND CHILDRENS DENTISTRY
Farrey implant & Cosmetic Family
First Class Pediatric Dentistry
Franklin Dental
Franklin Dental
Franklin Dental
Fulton County Dept of Health
GC Duluth Pediatrics Inc
General Family Dentistry
GENTLE DENTAL
GRAYSON PEDIATRIC DENTISTRY
GREAT EXPRESSIONS DENTAL CENTERS
Great Expressions Dental Centers
Great Expressions Dental Centers
Great Smile Dental
GWINNETT PEDIATRIC DENTISTRY
Happy Children Pediatric Dentist
HERRIN PEDIATRIC DENTISTRY
HOME GROWN
Hughes Spalding/CHOA
Huynh Loan H MD
Hwy 138 Dental
IMAGIX DENTAL III
J & J FAMILY DENTISTRY
Jason Allred DMD
JD MURRAY DDS & ASSOCIATES
JEFFREY C BLANKENSHIP DMD
JOE LESTER DDS
Just Kids Dentistry
KAISER CONYERS
KAISER PERMANENTE
Kaiser Permanente Douglasville
Kaiser Permanente Cumberland
KAISER-SOUTHWOOD
Kids & Teens Primary Health
KIDS DENTAL
Kidztown Dental.
KOOL SMILES
KOOL SMILES
KOOL SMILES
KOOL SMILES DENTIST
KOOLSMILES #016
KWON PEDIATRIC DENTISTRY
Kwon Pediatric Dentistry
Lake Point Dental
Lawrenceville Pediatric Dentistr
Lithonia Pediatric Dentistry
LITTLE PEACHES PED DENTISTRY
Little Pearls Pediatric Dentistr
Mableton Family Dentistry
Mini Smiles Pediatric Dentistry
Morrow Family Dentistry
Mustard Seed Pediatric Dentistry
My Kidz Dental
NANSTON DENTAL GROUP
Nia Pediatric Dentistry
NOAHS ARK CHILDRENS DENTISTRY
North Dekalb Health Center Denta
North Georgia Pediatric Dentistr
NUKOA FAMILY DENTISTRY
Omega Pediatrics
Park Village Dental Group
PAUL LYLE GLASSER
Peachtree Children's Dentistry
PEACHTREE CHILDREN'S DENTISTRY
PEDIATRIC DENTISTRY
PERIMETER PEDIATRIC DENTISTRY
PETULA HOM DDS
PHILIP JEON, DDS
POST OAK PEDIATRIC DENTISTRY
Princeton Lakes
RIGHT TOUCH DENTAL
Riverdale Denter Center
SERENE DENTAL CARE, LLC
SMILE MAGIC DENTISTRY
SMILES FOR KIDS
SMYRNA PEDIATRIC DENTISTRY
SOFT HEART DENTISTRY
SOUTHERN CRESCENT PEDIATRICS
SOUTHERN SMILES
SOUTHSIDE MEDICAL CENTER
SOUTHSIDE MEDICAL CENTER
Sprout Pediatric Dentistry
STONECREST CHILDRENS DENTISTRY
SUGARLOAF CHILDREN'S DENTISTRY
SUGARLOAF FAMILY DENTIST
T O VINSON HEALTH CENTER
TeamCare
TEBO DENTAL GROUP
TEBO DENTISTRY FOR KIDS
Tebo Dentistry for Kids
The Children's Dental Group
VITAL SMILES GEORGIA, P.C.
West End Medical Center
WEST GEORGIA DENTAL
WHITEFOORD MEDICAL SERVICES
Zona Dental
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EHS 2023-2024
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