4-Year-Old Preschool Registration Form printable pdf download

Maquoketa Community School District

4-YEAR-OLD PRESCHOOL REGISTRATION FORM

2016-2017

____________________________________

________________________

__________________

Child’s Legal Last Name

First Name

Middle Name

____________________

_____

________________________

_____________________________

Date of Birth

Gender

Phone Number

County

_____________________________________

______

________

___________________________________________

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 _____________________

____________________________________________________________________________________________________________

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 ____________________________

____________________________________________________________________________________________________________

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 ____________________________

____________________________________________________________________________________________________________

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

4-Year-Old Preschool Registration Form

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