Preschool Program Student Registration Form	Page 1 of 2

Child’s Legal Name:	______________________________________________________________________________ (As it appears on Birth Certificate)	First	Middle	Last
Child’s Home Address: ______________________________________________________________________________ Street Address
______________________________________________________________________________ City	State	Zip Code
Child’s Home Phone:	_(________)__________-______________________

Primary Email Address of Parent or Guardian:________________________________________

Gender:	Male	Female

Ethnicity:	Asian/Pacific Islander

American Indian/Alaskan

Black/Non-Hispanic

Multi-Racial

Hispanic

White/Non-Hispanic

Child’s Date of Birth:_____/_____/ ___________(MM/DD/YYYY)

Place of Birth:___________________________________

City & State or County & State as on Birth Certificate

Social Security Number:________-______-___________

Birth Certificate Number:_________________________

Primary Language Spoken in Child’s Home:_______________________________________________________________

Previous School Attended (if applicable):_________________________________________________________________

Has the Child had previous intervention services?	Yes	No	If yes, describe and provide location below:

____________________________________________ Description of Service
____________________________________________

__________________________________________________ Location
__________________________________________________

Description of Service

Name of Natural or Adoptive Mother:

Location

Name of Natural or Adoptive Father:

_____________________________________________	_____________________________________________ First	Middle	Last	First	Middle	Last

With whom does the Child reside? Name:________________________________________	Name:________________________________________
First	Middle	Last	First	Middle	Last

Relationship: Occupation:

Address:

________________________________ ________________________________

________________________________

Relationship: Occupation:

Address:

________________________________ ________________________________

________________________________

(If different from Child’s Address)	Street	(If different from Child’s Address)	Street ________________________________                                              ________________________________ City                                            State           Zip Code                                                                         City                                            State	Zip Code

Bus. Phone:	_(_____)_____-________ ext.________	Bus. Phone:	_(_____)_____-________ ext.________

Parents’ Marital Status:

Sibling Name

Married	Single

Relationship

Separated

Age

Divorced

Lives with Student?

____________________________________ ____________________________________
____________________________________

________________ ________________
________________

__________       Yes                       No __________       Yes                       No
__________	Yes	No

Page 2 of 2 Emergency Information
Adults to whom the Child may be released in an emergency situation, if the Child is ill or needs medical attention:

Name ____________________________________
____________________________________

Relationship ________________
________________

Phone Number

_(______)_______-__________ ext.________

_(______)_______-__________ ext.________

Family Physician:

Family Dentist:

__________________________________

__________________________________

Phone: _(______)_______-__________

Phone: _(______)_______-__________

Please list any allergies, medications taken regularly, health impairments, or handicaps, to which school personnel or a physician giving emergency medical treatment should be alerted: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________

My signature below certifies that all the information given on this registration form is true and accurate to the best of my knowledge.

Signature:__________________________________________________________	Date:_____________________

Hamilton County Educational Service Center c/o Stacie McMahon Early Learning Program 924 Waycross Road Cincinnati, Ohio 45240
OR email to: stacie.mcmahon @HCESC.org