School Year

What school year are you applying for?

 

Child's Information

Child's name

First name:
 
Middle name:
 
Last name:
 

Current address of the child

Street Name:
 
Apt #:
 
City:
 
State:
 
ZIP:
 

Child's birthday

Month:
 
Day:
 
Year:
 

What school are you zoned for?

 
 

Parent/Guardian's Information

Your name

First name:
 
Middle name:
 
Last name:
 

Your relationship to the child

 

Your phone number

Home/Cell #:
 
Work #:
 

Your email address

 

Family

Parent/Guardian's marital status

 

Highest level of education of parents

Mother:
 
Father:
 

Is parent currently on military deployment?

 

Was mother or father a teen parent?

 

Is parent incarcerated?

 

Does the child live with relatives other than parents?

 

If yes, what is the relationship of the relative to the child?

 

Is the child in foster care?

 

Homelessness

Is the child's current address, listed above, considered a temporary living arrangement?

 

If yes, what is the reason for the temporary living arrangement?

 

Child's History

Does the child have an IEP (Individual Education Plan) for special education services?

 

If yes, what is the IEP for this child?

Please provide as much detail as possible.
 

Is English the child's second language?

 

If yes, what is the child's primary language?

 

Has the child been exposed to domestic violence?

 

Has the child been exposed to substance abuse?

 
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