New Student Registration Form New Student Registration FormStart Date* Date Format: MM slash DD slash YYYY Basic InformationStudent’s Full Name* First Last Grade Registering for*Will your child be half-day or full-day? (only applies for Nursery and Pre-K)*Half-DayFull-DayAddress* Street Address City State / Province / Region ZIP / Postal Code Gender*Date of Birth* Date Format: MM slash DD slash YYYY Ethnicity: (Check all that apply)* American Indian or Alaskan Native Black or African American (non-Hispanic origin) o Asian Native Hawaiian or Pacific Islander Hispanic or Latino White (non-Hispanic origin) Multi-racial (non-Hispanic origin) What school(s) has your child attended*Does your child have an IEP or 504?*YesNoMaybeIf child has an IEP or 504, mark all that apply:* Early Intervention Services o Speech Physical Therapy Occupational Therapy SETSS SEIT Time and a Half Other Other*Has your child ever received services in the past? Check all that apply:* Early Intervention Services o Speech Physical Therapy Occupational Therapy SETSS SEIT Time and a Half Other Other*Any pertinent medical information or allergiesFamily InformationStudent’s Parents: (check all that apply)*MarriedSingleSeparatedDivorcedPartnersLanguages other than English spoken at home*Is any parent serving in the military:*YesNoIs any parent a member of the clergy:*YesNoParent #1:Parent #1 Full Name* Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Last Address if different from Student Street Address City State / Province / Region ZIP / Postal Code Occupation*Cell Phone*Home Phone*Email Address* Parent #2 Full Name* Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Last Address if different from Student Street Address City State / Province / Region ZIP / Postal Code Occupation*Cell Phone*Home Phone*Email Address* Sibling #1 NameSibling #1 Date of BirthSibling #2 NameSibling #2 Date of BirthSibling #3 NameSibling #3 Date of BirthFamily House of WorshipHow did you hear about us? (Check all that apply)* Another Parent Neighbor Advertisement Other: OtherAdditional Comments
