CENSUS INFORMATION

Please complete this card ONLY if you live in District 112
and have children ages birth to 5 years old (in your home),
not yet enrolled in kindergarten.

You may submit your Census Information using the form below.

Child’s full legal name  Boy Girl
                                             First                                         Middle                                     Last
Birth date //
                   month    day     year
Child’s full legal name  Boy Girl
                                             First                                         Middle                                     Last
Birth date //
                   month    day     year
Child’s full legal name  Boy Girl
                                             First                                         Middle                                      Last
Birth date //
                   month    day     year

Father/Guardian   Mother/Guardian
Father/Guardian Cellphone  Mother/Guardian Cellphone

Address:
Street   City  Zip
Home phone  


I have another child/other children already attending school. No  Yes
         
           Child’s name (already attending school)                 Name of school they attend

         
           Child’s name (already attending school)                 Name of school they attend

         
          Child’s name (already attending school)                 Name of school they attend