Child's Namerequired

Child's Gender*

Male Female

Child's Birthdaterequired

MM/DD/YY

Parent's Namerequired

Address 1required

Cityrequired

Staterequired

Ziprequired

Phone Numberrequired

Email Field

Where will your child be attending kindergarten?

Language Spoken in Home

English Spanish Hmong Other

Has your child had an early childhood screening or received special education services, including speech?

Yes No

Examples:

You will be contacted with a confirmation of date and time. Every effort will be made to accommodate your needs.

Interpreter

My child and/or I need an interpreter.

Yes No