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CPSE Registration Questionnaire
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* Indicates required question
Child's First Name/Primer nombre del estudiante
*
Your answer
Child's Last Name/Apellido del estudiante
*
Your answer
Child's Date of Birth/Fecha de nacimiento del estudiante
*
MM
/
DD
/
YYYY
Please select one of the following: /Seleccione uno de los siguientes:
A- This household is new to the district./Este hogar es nuevo en el distrito.
B- This household currently has one or more students registered with the district./Este hogar actualmente tiene uno o más estudiantes registrados en el distrito.
C- This household previously had one or more students registered with the district./Este hogar anteriormente tenía uno o más estudiantes registrados en el distrito.
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Parent/Guardian First Name/Nombre de padre/madre/tutor
*
Your answer
Parent/Guardian Last Name/Apellido de padre/madre/tutor
*
Your answer
Contact Email Address/Correo electrónico
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Your answer
Contact Number/número de contacto
*
Your answer
Street Address (Please include apartment number if applicable)/Domicilio (por favor incluya el número de apartamento si corresponde)
*
Your answer
City, State, Zip/Ciudad, Estado, Código Postal
*
Your answer
Is your child currently receiving Early Intervention services?/¿Su hijo/a recibe actualmente servicios de intervención temprana?
*
Yes/Si
No/No
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