First Name
Last Name
Gender (Optional) --------- Female Female-to-male (FtM) Male Male-to-female (MtF) Non-binary/Third gender Prefer not to say Prefer to self-describe Unknown
Education --------- Educational Level Unknown No High School Some High School High School Diploma Or Equivalent Some College Associate's Degree Bachelor's Or Four-year Degree Graduate Or Professional Degree Unknown
Relationship to Child --------- Aunt Father (adoptive) Father (biological) Father (foster) Father (step) Grandfather Grandmother Guardian Mother (adoptive) Mother (biological) Mother (foster) Mother (step) Other Sibling Uncle
Street 1
Street 2
City --------- Abercrombie Abilene Addison Alice Allen Alpine Amarillo Anderson Apex Arlington Aubrey Austin Azle Bartlett Bastrop Bedford Bee Caves Bellaire Belton Bertram Bevil Oaks Big Spring Bixby Boerne Brownsville Bryan Buda Bullard Burnet Carrollton Cedar Creek Cedar Park Cedar Rapids Chappell Hill Coeur D'Lane College Station Conroe Coppell Copper Canyon Corpus Christi Coupland Creedmoor Cypress Dale Dallas De Berry Del Valle Denton Dime Box Driftwood Dripping Springs Edinburg Edna El Paso Elgin Euless Fischer Flatonia Florence Flower Mound Fort Hood Fort Worth Fredericksburg Frisco Galveston Georgetown Giddings Granbury Grand Prairie Granger Granite Shoals Grapevine Hays Hewitt Houston Humble Hutto Irving Jacksonville Jarrell Johnson City Jollyville Jonestown Jourdanton Katy Keller Kempnen Killeen Kingsland Kingwood Kyle La Grange La Ward Lago Vista Lakeway Lampasas Laredo Leander Levelland Lewisville Lexington Liberty Hill Little River Academy Livingston Lockhart Longview Lubbock Lufkin Luling Magnolia Manchaca Manor Mansfield Marble Falls Marshall Ford Martindale Maxwell Mc Dade Mcallen Mckinney Midland Missouri City Moody Muldoon Navasota Nederland New Braunfels Oak Hill Odessa Paige Pampa Pasadena Pflugerville Pipe Creek Plano Port Arthur Portland Raleigh Red Rock Richardson Rio Grande City Rio Piedras Rockdale Rockport Rockwall Rollingwood Round Rock Rowlett Rural San Angelo San Antonio San Diego San Jose San Juan San Marcos Seguin Sherman Smithville Spicewood Spring Stafford Sugar Land Sunset Valley Taylor Temple Texas City The Colony The Hills The Woodlands Thorndale Thrall Tomball Trophy Club Universal City Victoria Waco Weslaco West Columbia West Lake Hills White Oak Wimberley Witchita Falls
State --------- Alabama Alaska Alberta American Samoa Arizona Arkansas British Columbia California Canal Zone Colorado Connecticut Delaware District Of Columbia Federated States Of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Marshall Islands Maryland Massachusetts Michigan Military-Americas Military-Europe Military-Pacific Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland Newfoundland & Labrador North Carolina North Dakota Northern Mariana Islands Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Republic Of Palau Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon
Zip
Phone 1 --------- cell home unknown work
--------- alternate primary
Phone 2 --------- cell home unknown work
Primary
Secondary
Third
Fourth
Best Contact Time
Best Contact Method --------- email phone
Date of Birth (yyyy-mm-dd)
Twin or Triplet? --------- Twins Triplets Quadruplets Quintuplets Unknown (or before 07/10/2019)
How well does this child know English? --------- Some Not at all Well Very Well
Please check all that apply to this child: Hispanic or Latino? Has Siblings? More than 3 weeks Premature? Bilingual?
Racial Affiliation --------- Asian Black or African American Caucasian Native American Native Hawaiian or Pacific Islander Other --------- Asian Black or African American Caucasian Native American Native Hawaiian or Pacific Islander Other --------- Asian Black or African American Caucasian Native American Native Hawaiian or Pacific Islander Other
Developmental Diganoses --------- ADD/ADHD Anxiety Autism Spectrum Disorder Central Auditory Processing Disorder Color Blindness Depression Down Syndrome Dyslexia Language Delay or Disorder OCD Other Other Learning Disability Seizure Disorder --------- ADD/ADHD Anxiety Autism Spectrum Disorder Central Auditory Processing Disorder Color Blindness Depression Down Syndrome Dyslexia Language Delay or Disorder OCD Other Other Learning Disability Seizure Disorder --------- ADD/ADHD Anxiety Autism Spectrum Disorder Central Auditory Processing Disorder Color Blindness Depression Down Syndrome Dyslexia Language Delay or Disorder OCD Other Other Learning Disability Seizure Disorder
Scanning Eligibility --------- Braces Head trauma Left-handed Metal tooth fillings Permanent retainer --------- Braces Head trauma Left-handed Metal tooth fillings Permanent retainer --------- Braces Head trauma Left-handed Metal tooth fillings Permanent retainer
How did you hear about us? --------- ACE Academy Add to Database form All Austin Cooperative Nursery School Any Baby Can Austin American Statesman Austin Children's Garden Austin Community College (ACC) Austin Family Magazine 2015 Austin Independent School District (AISD) Austin Maker Faire Austin Nature & Science Center Austin Play Garden Austin Public Libraries Austin STEM Academy Austin Zoo Autism Speaks AVANCE Baby Extravaganza Blanton Museum Bookspring Brentwood Christian School Bullock Museum Called In Child Craft Schools Child Inc. Child's Day CommUnityCare Health Centers Copernicus STEM, Language and Arts Academy Creative Action Darwin Day Dia de los Ninos Spanish Immersion Preschool Discovery School Easterseals Ebenezer Child Development Center Eco Kids Preschool Ecole Jean Jacques Rousseau Elisabet Ney Museum Escuelita Del Alma Explore UT Extend-A-Care Facebook First English Lutheran Church Child Development Center Flyer Four Seasons Community School Friend Girl Day at UT Austin Girlstart Goodwill Excel Center Growing Imaginations Growing Tree Learning Center Habibi's Hutch Preschool Harry Ransom Center Health and Human Services Health and Lifestyle Expo Holden List Holy Family Catholic School Hot Science--Cool Talks Huston-Tillotson University Hyde Park Preschool Kid Spa Austin Kidworks Know Events Longhorn Halloween Mainspring Schools Neill-Cochran House Museum Northwest Montessori House of Children Online Recruitment Form Open Door Preschools Other Parenting Fair 2000 Parks and Recreation Department Project Hopes Roots & Wings Festival Round Rock Leader Sibling Referral St. John's Lutheran Child Care Center St. Louise House TDH Texas Memorial Museum The Dragonfly Forest Thinkery Toybrary Umlauf University United Methodist Church Early Childhood Center UT Child Development Center UT Interactive Web Site Women, Infants and Children (WIC) Workforce Solutions YMCA Zilker Botanical Garden
What language is spoken most by you and others in your household? --------- African Arabic ASL Bengali Cantonese Chinese English French German Greek Gujurati Hindi Italian Japanese Korean Mandarin Romanian Russian Spanish Taiwanese Tamil Thai Urdu Vietnamese
What other languages are spoken in your household? --------- African Arabic ASL Bengali Cantonese Chinese English French German Greek Gujurati Hindi Italian Japanese Korean Mandarin Romanian Russian Spanish Taiwanese Tamil Thai Urdu Vietnamese --------- African Arabic ASL Bengali Cantonese Chinese English French German Greek Gujurati Hindi Italian Japanese Korean Mandarin Romanian Russian Spanish Taiwanese Tamil Thai Urdu Vietnamese
Languages spoken in your household not on this list:
