RUSSELL INDEPENDENT SCHOOLS PRESCHOOL 2014-2015
Enrollment Date______
Student Name______Sex: M F
Last First Middle
Social Security Number______
Student’s Street
Address______City______Zip______
Student’s Mailing
Address______City______Zip______
Home Phone ______Dad’s Cell Phone______Mom’s Cell Phone______
School District of Residence______
Date of Birth______Place of Birth (County & State)______
Student’s Race: ______White (Non-Hispanic) ______Black (Non-Hispanic) ______Hispanic ______Asian/Pacific Islander
______American Indian/Alaskan Native ______Other
Does your child have any special needs that require accommodations at school? Y N If yes, what needs?
what is the language most frequently spoken at home? ____________
which language did your child learn when he/she first began to talk? ______
what language does your child most frequently speak at home? _________
what language do you most frequently speak to your child? ______
Father’s Name______Living_____ Deceased_____
Last First Middle
Street Address______City______Zip______
Home Work
Phone______Employer______Phone______
Father’s Nationality______
Mother’s Name______Living_____ Deceased_____
Last First Maiden
Street Address______City______Zip______
Home Work
Phone______Employer______Phone______
Mother’s Nationality______
Are Parents Married_____ Separated_____ Divorced_____ Widowed_____ Single_____
Name of Stepfather (if applicable)______
Name of Stepmother (if applicable)______
If Student Does Not Live With Parents, Please Complete The Following Information About the Person(s) the Student Lives With
Name______Relationship______
Street Address______City______Zip______
Mailing Address______City______Zip______
Phone______Does Person(s) Have Legal Guardianship/Custody Papers? Yes______No______
Name & Address of Last School Attended______
INFORMATION ON OTHER CHILDREN LIVING IN THE SAME HOUSE (Use Back of Sheet if Additional Space is Needed)
First & Last Name Birth Date School Attending Grade Relationship to student
______
______
______
Student Will Ride Bus Both Ways______To School Only______From School Only______Will Not Ride Bus______
GENERAL INFORMATION
/ Parental Status (check one) One Two Foster Grandparents Other / Number in Family ___Number of Children ______By age 0-3 ____ 4-5 ____ / Number in Household ______
INCOME SUPPORT: / TANF: Yes No / SSI: Yes No / WIC: Yes No
FAMILY INCOME
Family Member / Date / Source / Amount / PerTotal yearly income of family