Roster Information Form
Today's Date
-
Month
-
Day
Year
Date
Child Information
Child's Name
First Name
Last Name
Child's Middle Name
Name Child is called
Child's Social Security Number
Child's Date of Birth
-
Month
-
Day
Year
Date
Child's Gender
Male
Female
Date enrolled in PreK
-
Month
-
Day
Year
Date
Parent/Guardian Information
Name
First Name
Last Name
Relationship to Child
Mother
Father
Grandparent
Guardian
Parent/Guardian Email
*
example@example.com
Zipcode:
1. Is your child’s ethnicity Hispanic/Latino/Spanish Origin, regardless of race? (¿Es Ud. Hispano/Latino o de Origen Hispano, sin importar la raza?)
Yes (Si)
No
Decline to Answer (negarse a contester)
2. Is your child:
a. White – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. (Blanco – Una persona que tiene orígenes en los pueblos provenientes de Europa, el Medio Oriente, o Africa del Norte).
b. Asian – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. (Asiática – Una persona con orígenes en los pueblos provenientes del Lejano Oriente, Suroeste de Asia, o el subcontinente Hindú incluyendo, a Cambodia, China, India, Japón, Corea, Malasia, Pakistán, Las Filipinas, Tailandia, y Vietnam.)
c. Native Hawaiian or Other Pacific Islander – A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. (Nativo de Hawaii u Otra Isla del Pacífico – Una persona con orígenes en los pueblos provenientes de Hawaii, Guam, Samoa, u otra Isla del Pacifico.)
d. Black or African American – A person having origins in any of the Black racial groups of Africa. (Negro o Afro Americano – Una persona con orígenes en los pueblos provenientes del Africa o en grupo racial Negro.)
e. American Indian or Alaskan Native – A person having origins in any of the original peoples of North and South America including Central America, who maintains a tribal affiliation or community attachment. (Indio Americano o Nativo de Alaska – Una persona con orígenes en los pueblos provenientes de América Del Norte y del Sur, incluyendo América Central, que mantiene una afiliación tribal o comunitaria.)
f. Decline to Answer (negarse a contester)
3. What is your child's primary language?
English
A language other than English
4. Was your child born as a:
Single Birth
Twin (2)
Triplet (3)
Quadruplet (4)
Quintuplet (5)
5. Does your child receive Special Education Services?
Yes
No
5.a. If Yes, indicate which of the following Special Education Services your child receives.
Individual Education Program (IEP) (Part B, Section 619, IDEA)
504 Plan/Individual Accommodation Plan (IAP) (Section 504 of the Rehabilitation Act of 1973)
6. Does your child receive any of the following services?
Childcare and Parent Services (CAPS) (child care subsidy program)
Child and Adult Care Food Program (CACFP)
SSI
Supplemental Nutrition Assistance Program (TANF)
Medicaid
Temporary Assistance for Needy Families (TANF)
Foster Care
Will the PreK center be providing transportation for your child?
Yes
No
Signer's Name
First Name
Last Name
Signature
Submit
Should be Empty: