Richmond Public Schools s1

Richmond Public Schools

PRESCHOOL PROGRAM REGISTRATION FORM

Date of Application: ______
Zone School/Community Center ______2nd Choice: ______
Student’s Last Name: ______First Name:______Middle______
Birth date: ______Sex: ___ Birth Certificate #: ______Place of Birth (State):______
Health Insurance Provider: ______Health Insurance Number:______Email Address ______
B H AI W A
Ethnic Code/Race (Circle One)
Other ______/ EN SP FR GE
Native Language (Circle One)
Other______/ Parental Status (Circle One)
S=Single M=Married
G=Legal Guardian F=Foster
Street Address Apt. # / City, State Zip Code / Phone # ______
Cell # ______
Work # ______
Mother’s Birth Date / Ethnic Code / Last Name / First Name / SS#
Father’s Birth Date / Ethnic Code / Last Name / First Name / SS#
Guardian’s Birth Date / Ethnic Code / Last Name / First Name / SS#
Guardian relationship to child: (aunt, uncle, foster parent, sibling, other______)
Was child referred by an Agency/Professional?
(Circle One) Yes No / By Whom (name/title) / Reason for Referral
EMERGENCY CONTACTS (Other Than Parent/Guardian)
______
Name Relationship to Child Phone #
______
Name Relationship to Child Phone #
______
Physician Address Phone #
______
Dentist Address Phone #

HOUSEHOLD MEMBER INFORMATION (Adults & Children)

ADULTS Living in Household
Last/First Name / Relationship to child / Sex / Educ. Level:
H.S. Grad, GED, College / Employer / Employer/
Work
Phone # / Employment Status
FT PT / Currently taking
Class Training
1.
2.
3.
CHILDREN Living in Household (LIST APPLICANT FIRST, then other children )
Last/First Name / Relationship to
Child / Former /Current Preschool
Child (specify) / Date of Birth / Sex / School
1.
2.
3.
4.
5.

Revised 2015