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Prairie Seeds Academy
Registration form

Child's Information
 
Child's Legal Name:

Last First Middle
Home Address:

Street Name Apt/Building/House #


City: State: Zip
Home Phone: Other Phone:
Date of Birth:

Month Date Year
Sex: Male Female
Place of Birth:

City State County Country
Immigrant? Yes No Arrival into U.S.:
(Optional)




Month Year
Racial/Ethnic Group:

African American American/Alaskan Asian/Pacific Islander

Caucasian/Non-Hispanic Hispanic Others
Social Security No: - - Current Grade:
(Optional)







Child's History

Name of Last School Attended: Did this child attend preschool? Yes No
Address City State Zip Phone no.
Has this child ever repeated a grade? Yes, which grade(s)? No
What language(s) is (are) spoken at home?
What language is this child most comfortable with?

 

Parent Information

Child lives with: Both Parents Mother Father Others
Name of Mother/Stepmother/Guardian:
Employer:

Name Phone No. Email
Name of Father/Stepfather/Guardian:
Employer:

Name Phone No. Email
Please list TWO emergency contacts. If your child becomes ill or if the school closes for an emergency, we must be able to contact someone.
Full Name Complete Address Phone no. Relationship
Full Name Complete Address Phone no. Relationship
Special Services: Check all that apply.
ESL services needed or provided at previous school Counseling Services
Special Education Medications

 Tested, but did not qualify
Type:

 Has an IEP
Reasons:
Please explain any special needs this child may have (be very specific)
List child's major health problems (if any)
Family Physician

Name Phone No.
Hospital/Clinic

Name Complete Address
List brothers or sisters currently at Prairie Seeds Academy
Name: Date of Birth:

Grade:
Name: Date of Birth Grade:
Name: Date of Birth

Grade:
Name: Date of Birth

Grade:
Name: Date of Birth

Grade:
Name: Date of Birth

Grade:


Prairie Seeds Academy does not discriminate because of sex, creed, color, religion, national origin, disability, marital status, status with regard to public assistance, sexual orientation or any other protected class status defined by local, state or federal laws.