Mother's First and Last Name ***
Father's First and Last Name **
Address *
City
State
Zip Code
Phone 1
Phone 2
Email Address
Are you a first-time parent? YesNo*
Race/Ethnicity
Language spoken
Insurance PrivateMedicaid
Child 1 First and Last Name
Child 1 Birthdate
Child 1 Gender BoyGirl
Child 1 Ethnicity
Developmental Concerns
Child 2 First and Last Name
Child 2 Birthdate
Child 2 Gender BoyGirl
Child 2 Ethnicity
Child 3 First and Last Name
Child 3 Birthdate
Child 3 Gender BoyGirl
Child 3 Ethnicity
School District **Hancock
What are the best times and days for a personal visit? (Check all that apply)
Morning Afternoon Evening Mon Tues Wed Thurs Fri Sat
Do all parents/guardians work outside the home? Yes No
Does your child attend preschool or child care? If so, where and since what age?
Hancock Place School District does not discriminate on the basis of race, color, national origin, sex, age, or disability in admission to its programs, services, or activities, in access to them, in treatment of individuals, or in any aspect of their operations. The lack of English language skills shall not be a barrier to admission or participation in the district’s activities and programs. Hancock Place School District also does not discriminate in its hiring or employment practices.