Western Dubuque County Community School District
Community-Based Preschool Registration
2/17/2019
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Community-Based Preschool Registration Form

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Community-based Attendance Center
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Community-based Preschool program
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Date Registering (mm/dd/yyyy)
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Student Start Date (mm/dd/yyyy)

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STUDENT INFORMATION

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(Student's Last Name)
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(Student's First Name)
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(Student's Middle Name)
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Male  Female  
Student's Gender/Sex
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Student's Birth Date (mm/dd/yyyy)

Student's Social Security Number

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Student's Ethnic Background: Is this student Hispanic/Latino?
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Student's Race

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PRIMARY HOUSEHOLD (Parent/Guardian with whom the student resides)

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(Father's/Guardian's Last Name)

(Father's/Guardian's First Name)

(Father's/Guardian's Middle Name)

(Mother's/Guardian's Last Name)

(Mother's/Guardian's First Name)

(Mother's/Guardian's Middle Name)
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Home Address (Include PO Box #)
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Are you a resident of the Western Dubuque School District?
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City
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State
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Zip Code
*()- Ext.
Parent/Guardian Home Phone Number

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HOME LANGUAGE

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Student's Birth Place

If not born in the United States, date of entry into the United States (mm/dd/yyyy)

If student previously attended school outside of the U.S., provide date student entered a U.S. school (mm/dd/yyyy)

Most Recent Previous School of Attendance in the U.S.

Previous School of Attendance Address

Dates Attended

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Previous School of Attendance in the U.S.

Previous School of Attendance Address

Dates Attended

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Previous School of Attendance in the U.S.

Previous School of Attendance Address

Dates Attended

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Language Spoken in the Home
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If available, in what language would you prefer to receive communication from the school?
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Yes  No  
Is your child's first-learned or home language anything other than English?

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If your child's first-learned or home language is not English, please complete the following:


What language did your child learn when he/she first began to talk?

What language does your child most frequently speak at home?

In what language does Father/Guardian most frequently speak to child?

In what language does Mother/Guardian most frequently speak to child?

Please describe the language understood by your child.

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TRANSPORTATION INFORMATION

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County of Residence
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Will student require bussing?

Student bussed to/from
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I give permission for my child to be transported for school field trips and events.

If Other Location, Provide Contact Name (ex. day-care provider, etc.)
()- Ext.
Contact Phone Number at Other Location

Address for Other Location

City

(Additional transportation fees may apply. Please contact the Transportation Office at 563-744-3512.)

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Parent/Guardian Signature

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The policies of the Western Dubuque County Community School District shall provide educational programs, activities, and employment practices which do not discriminate on the basis of age, color, creed, national origin, race, religion, marital status, gender, sexual orientation, gender identity, socioeconomic status, physical or mental abiity or disability. The Western Dubuque County Community School District is an Equal Employment Opportunity/Affirmative Action employer. Any person having inquiries about this statement, please contact Tina Brestrup, Equity Coordinator at 563-744-3885 x 6010 or at tina.brestrup@wdbqschools.org
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