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 InitialFemaleMaleAddressTelephone No.*Child’s Date of Birth MM slash DD slash YYYY Place of Birth (City & State)EthnicityHispanic or Latino originNone-Hispanic or Latino originRace American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or other Pacific IslanderWhiteBi-Racial / Multi-RacialOtherExplainPrimary Home Language EnglishSpanishNative Central American, SouthAmerican Mexican LanguagesMiddle Eastern & South Asian LanguagesEast Asian LanguagesPacific LanguagesEuropean & Slavic LanguagesAfrican LanguagesOtherFamily Information Marital Status of Parent (s)SingleDivorcedSeparatedWidowedMarriedOtherMother’s/ Guardian’s Information Name* First Name Last Name AddressPhone*Alternate PhoneEmployer’s Name*OccupationBusiness Telephone No.Ext.Ethnicity Hispanic or Latino Asian Black or African American Native Hawaiian or other Pacific Islander White Bi-Racial / Multi-Racial Other ExplainFather’s/ Guardian’s InformationName* First Name Last Name AddressPhone*Alternate PhoneEmployer’s NameOccupationBusiness Telephone No.Ext.Ethnicity Hispanic or Latino Asian Black or African American Native Hawaiian or other Pacific Islander White Bi-Racial / Multi-Racial Other ExplainHead of Household FatherMotherOtherRelationshipDo 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 IEPPlease 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 printDate MM slash DD slash YYYY SignatureCommentsThis field is for validation purposes and should be left unchanged.
