PRE-REGISTRATION Pre-Registration Form "*" indicates required fields Pre-Registration form for Infant, Pre School, Before and After Care, Mini-Mountie Pre-K ProgramApplication Date MM slash DD slash YYYY Program (check all required) Infant Toddler Pre-K Mini-Mountie PK NCICC Before Care After Care Summer Camp Child’s Name* Date of Birth MM slash DD slash YYYY In order to complete your Registration; Please bring the following Items: Registration fee Non-refundable (If applicable) Child’s Immunization Record Programs for Parents Paper work (If applicable) Child’s Birth Certificate Child’s Social Security Card Child’s InformationChild’s Last Name* First Name* Middle Initial Female Male Address Telephone No.*Child’s Date of Birth MM slash DD slash YYYY Place of Birth (City & State) EthnicityHispanic or Latino origin None-Hispanic or Latino origin Race American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White Bi-Racial / Multi-Racial Other Explain Primary Home Language English Spanish Native Central American, South American Mexican Languages Middle Eastern & South Asian Languages East Asian Languages Pacific Languages European & Slavic Languages African Languages Other Family Information Marital Status of Parent (s)Single Divorced Separated Widowed Married Other Mother’s/ Guardian’s Information Name* First Name Last Name Address Phone*Alternate PhoneEmployer’s Name* Occupation Business Telephone No.Ext. Ethnicity Hispanic or Latino Asian Black or African American Native Hawaiian or other Pacific Islander White Bi-Racial / Multi-Racial Other Explain Father’s/ Guardian’s InformationName* First Name Last Name Address Phone*Alternate PhoneEmployer’s Name Occupation Business Telephone No.Ext. Ethnicity Hispanic or Latino Asian Black or African American Native Hawaiian or other Pacific Islander White Bi-Racial / Multi-Racial Other Explain Head of Household Father Mother Other Relationship Do you currently have a child/children in the program? Yes No Is the child in need of outside support? Physical therapy, speech etc. Please explainDoes child have an IEP Please note your answer will not determine us providing care for your child / children, your honesty helps us to continue the support needed. I have answer all questions to the best of my ability and will comply with all additional information needed upon initial interview. Parent / Guardian Name, please print Date MM slash DD slash YYYY SignatureEmailThis field is for validation purposes and should be left unchanged.
