Maquoketa Community School District
4-YEAR-OLD PRESCHOOL REGISTRATION FORM
2016-2017
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Child’s Legal Last Name
First Name
Middle Name
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Date of Birth
Gender
Phone Number
County
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Street Address
APT #
PO Box
City/Zip Code
Does this child have an IEP? ! Yes
! No
Is this child Hispanic/Latino? (Choose only one.) ! No, not Hispanic/Latino ! Yes, Hispanic/Latino
What is this child’s race? (Choose all that apply) ! American Indian or Alaska Native ! Asian ! Black or African American
! Native Hawaiian or Other Pacific Islander ! White
Birth Country _____________ Date of entry to USA ____________Primary Language Spoken in the Home ____________________
Language Spoken by Child First Four Years of Life if Not English _____________________
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Please give name and information about the adults living at the address listed above.
Relationship (circle one): Mother Father Step-mother Step-father Foster parent Legal guardian Grandparent Other
Name ____________________________________________________________ Home Phone ____________________________
Email Address _____________________________________________________ Cell Phone ______________________________
Employer _________________________________________________________ Work Phone ____________________________
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Relationship (circle one): Mother Father Step-mother Step-father Foster parent Legal guardian Grandparent Other
Name ____________________________________________________________ Home Phone ____________________________
Email Address _____________________________________________________ Cell Phone ______________________________
Employer _________________________________________________________ Work Phone ____________________________
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Parents divorced? ! Yes ! No Parents separated? ! Yes ! No Father deceased? ! Yes ! No Mother deceased? ! Yes ! No
If divorced or separated, is there an additional person to contact? ! Yes ! No Send Mailings to this Person? ! Yes ! No
Person’s Name _______________________________ Relationship ____________________Email Address___________________
Mailing Address _________________________________________________________ Phone _____________________________
Who has legal custody of this child? _____________________________ Are there any legal restrictions? ! Yes ! No
If yes, please provide legal documentation on any restrictions as required.
CONTINUED ON REVERSE