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 / Per
Total yearly income of family