Preschool Program Student Registration Form	Page 1 of 2

Child’s Legal Name:	______________________________________________________________________________ (As it appears on Birth Certificate)	First	Middle	Last
Child’s Home Address: ______________________________________________________________________________ Street Address
______________________________________________________________________________ City	State	Zip Code
Child’s Home Phone: (________)__________-__________________ District student lives in:______________________

Primary Email Address of Parent or Guardian:________________________________________

Gender:	Male	Female

Ethnicity:	Asian/Pacific Islander

American Indian/Alaskan

Black/Non-Hispanic

Multi-Racial

Hispanic

White/Non-Hispanic

Child’s Date of Birth:_____/_____/ ___________(MM/DD/YYYY)      Place of Birth:___________________________________ City & State or County & State as on Birth Certificate

Did a sibling attend the early childhood program?	Yes	No

If yes, name of sibling and year:__________________________________________

Primary Language Spoken in Child’s Home:_______________________________________________________________

Previous School Attended (if applicable):_________________________________________________________________

Has the Child had previous intervention services?     Yes	No	If yes, describe and provide location below:

____________________________________________ Description of Service ____________________________________________ Description of Service

Name of Natural or Adoptive Mother:

_____________________________________________ First	Middle	Last

__________________________________________________ Location __________________________________________________ Location

Name of Natural or Adoptive Father:

_____________________________________________ First	Middle	Last

With whom does the Child reside?

Name:________________________________________ First	Middle	Last
Relationship:	________________________________

Name:________________________________________ First	Middle	Last
Relationship:	________________________________

Occupation:

Address:

________________________________

________________________________

Occupation:

Address:

________________________________

________________________________

(If different from Child’s Address)	Street	(If different from Child’s Address)	Street ________________________________                                              ________________________________ City                                            State            Zip Code                                                                         City                                            State	Zip Code
Bus. Phone:	_(_____)_____-________ ext.________	Bus. Phone:	_(_____)_____-________ ext.________

Parents’ Marital Status:

Sibling Name

Married	Single

Relationship

Separated

Age

Divorced

Lives with Student?

____________________________________ ____________________________________
____________________________________

________________ ________________
________________

__________       Yes                       No __________       Yes                       No
__________	Yes	No

Page 2 of 2 Emergency Information
Adults to whom the Child may be released in an emergency situation, if the Child is ill or needs medical attention:

Name ____________________________________
____________________________________

Relationship ________________
________________

Phone Number

_(______)_______-__________ ext.________

_(______)_______-__________ ext.________

Family Physician:

Family Dentist:

__________________________________

__________________________________

Phone: _(______)_______-__________

Phone: _(______)_______-__________

Please list any allergies, medications taken regularly, health impairments, or handicaps, to which school personnel or a physician giving emergency medical treatment should be alerted: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________

My signature below certifies that all the information given on this registration form is true and accurate to the best of my knowledge.

Signature:__________________________________________________________	Date:_____________________

Please email this completed Registration form to meghan.ott@hcesc.org
If you have any questions about the program please email Jenny.griffith@hcesc.org

OFFICE USE ONLY: FOR PROGRAM SUPERVISOR COMPLETION ONLY

First Day in Classroom _____

Session	A	P