Preschool Intake Form Part I: Child And Family Information - Medford Public Schools

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START DATE: ____/____/____
MEDFORD PUBLIC SCHOOLS
McGLYNN PRESCHOOL INTAKE FORM
PART I: CHILD AND FAMILY INFORMATION
Application Date: _____/______/_______
1. CHILD INFORMATION
Child’s Name:_______________________ Date of Birth: ____/____/____ Gender:
M
F
Social Security #:_________________________ Primary Language:______________________
Race :
Caucasian/
Black/
Latino/
Asian/Pacific
Native
Other
Non-Hispanic
Hispanic
Hispanic
Islander
American
______________
Country of Birth
Ethnic Background
: _________________________
:_____________________
Child’s disability, if any: __________________________________________________________
Did child receive Early Intervention Services?
Yes
No
Does child have an Individualized Education Program (IEP)?
Yes
No
In
process
If yes, please describe the special education services your child receives.
2. FAMILY / HOUSEHOLD INFORMATION
Parent/Guardian #1
Name:___________________________ Relationship to Child:___________________
Address:___________________________ City/State/Zip:_____________________
Home Telephone #:_________________ Work Telephone #:___________________
Cell Telephone#: _________________
Email: ____________________________
Employment:
Employed full-time
Unemployed
Child Support
Employed part-time
Retired
Disabled
Other______________________________
Parent/Guardian’s disability, if any:_______________________________________________

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