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Pike Road City Registration
Contact Information
*
1.
Please Tell Us About Yourself:
(Required.)
Your First Name
Your Last Name
Your Street or Mailing Address
Your City
Your State
Your Zip
Daytime Phone
Evening Phone
Email:
2.
How would you identify your race:
Caucasian
African American
Native American
Hispanic
Asian
Two or More Races
Prefer Not to Answer
3.
Please Tell us About Your Ethnicity
Not Hispanic
Hispanic
Prefer Not to Answer
4.
What is the Primary Language Spoken In your Home:
English
Spanish
Other
5.
Are you the Parent of a Child with Disabilities ages birth to 26
(Includes Parent, Grandparent, Foster or Adoptive, Surrogate, or Relative of a Child with a Disability
Yes
No