CENTRALIA SCHOOL DISTRICT

6625 La Palma Ave. • Buena Park 90620 • (714) 228-3153

State Preschool Programs PRE-Registration

Student information . . .(please print)

Last Name / First Name / Middle Name/Initial / Sex
Last Name / First Name / Middle Name/Initial / Sex
Address / Apt. # / City / Zip
Home
Phone:() / Alternate
Phone:() / Date
of Birth:Month/Day/Year/
Birthplace
CityState / Country / (If born outside of the U.S.)
U.S. Entry Date
Please indicate any of your child’s
physical handicap or health problems:
Has your child ever participated in any of the following programs?(Please check all that apply)
Resource Special Day Class Title IDeaf Education Services Speech/Language Services
Learning Link Counseling Bilingual ServicesOther:(please list) None of the Above

Parent Information . . . (please print)

Head of Household: / Parent A: / Relationship: / Parent B: / Relationship:
Marital Status: /  Single Parent Household Cohabitating or living with Partner
 Married or Legal Domestic Partner Other:
Parent A / Last Name / First Name / Middle Name/Initial
Employer / City / Work Phone
()
Parent B / Last Name / First Name / Middle Name/Initial
Employer / City / Work Phone
()
Guardian/Custody(Please indicate Relationship):
Has there been a separation or divorce?Yes No /

With whom does child live?

Are both parents living?  Yes No If No: Father Mother Year deceased

Special family circumstances and/or custody problems:

Family Data . . . (please print)

Names of Brothers / Sisters Living in the Home /
Date of Birth
/ Others Living In Home /
Relationship

I affirm under penalty of perjury that the statements in this application are true to the best of my knowledge and belief. I will notify the agency when any change occurs in my eligibility status. The information pertaining to my eligibility is subject to review by State of California representatives.

If placed on a waiting list I understand that once a call is made for an open spot I have 48 hours to reply or my spot will be given to the next applicant.

Parent/Guardian SignatureDate

. . . For Office Use Only. . .
Program Site:
CNT/PSDNB/PSSM/PS / Sch. Yr.: / Date Rec’d:
Wait List: / Rank: / First Day of School:
Immunization / Birth Certificate / Residency Verification (within CentraliaSchool District)
Complete / Incomplete / TB Test: / Yes / School: / No / District:
Parent AMo. Income / Weekly / E/O Week / 2x Month / Monthly / Parent Unemployed / Family Size
$ / $ / $ / $ / $ / Parent A  Parent B 
Parent B Mo. Income / Weekly / E/O Week / 2x Month / Monthly / AFDC / FamilyMo. Income
$ / $ / $ / $ / $ / $ / $
NOTES: