3-Year-Old Preschool Registration Form
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2For Office Use Only:
Maquoketa Community School District
Rec’d Date__________
3-YEAR-OLD PRESCHOOL REGISTRATION FORM
Time:______________
$30 Fee Pd __________
2016-2017
Tuition is $120 per Month per Child
____________________________________
________________________
__________________
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 I Will Pay Monthly Tuition Yes No I Will Need Scholarship IF Available 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
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