* means that this question is required.

At the end of the survey, you will be asked to click DONE. When you do this, you should be returned to the first question of this form so that you can review your answers. Once you have completed the review, please click DONE for the second time. This formally submits the answers to us.

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* 1. Today's Date

Date

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* 2. Child's Last Name (*Must be same as on Birth Certificate)

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* 3. Child's First Name

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* 4. Child's Middle Name

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* 5. Did the child attend preschool?

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* 6. Name of Preschool Attended

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* 7. Child's Mother Maiden Name (** This information is required by the State.)

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* 8. Child's City of Birth

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* 9. Child's County of Birth

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* 10. Child's State of Birth

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* 11. Child's Country of Birth

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* 12. Child's Birth Certificate Number

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* 13. Gender

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* 14. Social Security Number

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* 15. Choose Only ONE Race

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* 16. Hispanic

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* 17. Address (* Must be a resident of Benton County)

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* 18. Birthdate

Date

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* 19. Custody of Child (** Proof of custody must be provided.)

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* 20. Parent/Legal Guardian (Living with Child)

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* 21. Home Telephone Number

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* 22. Cell Number

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* 23. Employer

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* 24. Work Number

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* 25. Relationship of this Person to Child

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* 26. Parent/Legal Guardian (Living with Child)

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* 27. Home Telephone Number

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* 28. Cell Number

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* 29. Employer

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* 30. Work Number

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* 31. Relationship of this Person to Child

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* 32. List any children you feel should be in separate classes and reason

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* 33. Emergency Contact #1

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* 34. Emergency Contact #2

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