Parent / Guardian Name *

Name of parent /guardian contacting us or completing this form.

First Name

Last Name

Pre-School Student Name *

List the primary child involved here. If any other children of your children are involved, identify them in the description box at the bottom of this form.

First Name

Last Name

Phone

(###)

###

####

Second Phone

(###)

###

####

Is your child in any of the following protected classes? *

Please select all options that apply

Minority Race

Female

Disabled (504 or IEP)

Religion

Foreign Nationality

Other (not listed)

None of These

If disabled above, is your child receiving any of these supports? *

Service Plan (Private School)

504 Plan for Disability Accommodations

IEP (Individualized Education Plan)

None of These