Pre-school and School-age Census Form

SHENENDEHOWA
CENTRAL SCHOOLS Preschool and School-age Census Form

Please fill out ONE form PER household address. Only list children who live in the SAME household on this form. It is not necessary to fill out this form if you do not have any children living in the household with you.

1. Father / Male Guardian: __________________________________________________________________
Last Name First Name Middle Initial

2. Mother / Female Guardian: _______________________________________________________________
Last Name First Name Middle Initial

Residential Address: _________________________________________________________________________

Mailing Address (if different): __________________________________________________________________

Home Phone Number: ___________________________________

ALL CHILDREN LIVING IN PRIMARY HOUSEHOLD UNDER THE AGE OF 21

First	Middle Name	Last	SEX M/F	Date of Birth	Relationship to Adults in HH		Race / Ethnic Group	School	Grade
					1.	2.
					1.	2.
					1.	2.
					1.	2.
					1.	2.
					1.	2.

Relationship of Household Adults to Children				Race/Ethnic Group Codes: Please list one only (required by No Child Left Behind Federal Legislation
FA	-Bio/Legal Father	MO	-Bio/Legal Mother	A	-Asian
SF	-Stepfather	SM	-Stepmother	B	-Black or African American
MG	-Legal Male Guardian	FG	-Legal Female Guardian	H	-Hispanic or Latino
FF	-Foster Father	FM	-Foster Mother	I	-American Indian or Alaskan Native
RM	-Other Male, Related**	RF	-Other Femal, Related**	M	-Multiracial
UM	-Other Male, Unrelated**	UF	-Other Female, Unelated**	P	-Native Hawaiian/Other Pacific Islander
S	-Self			W	-White
Please mail (in a stamped envelope), fax or drop off this form to the Registrar’s Office at the address / fax number listed above. Thank you for helping us find our next generation of students!