Census Form

Please note: This is NOT en enrollment form.

Heads of Household

Adult #1

First Name

Middle Initial

Last Name

Birthdate (mm/dd/yyyy)

Email

Cell Phone

Work Phone

Adult #2

First Name

Middle Initial

Last Name

Birthdate (mm/dd/yyyy)

Email

Cell Phone

Work Phone

Address

Street Address

Apt #

City

State

Zip Code

Home Phone

Additional Household Members

Please list ALL other people living in your family unit under 20 years of age.

Resident #1

First Name

Middle Initial

Last Name

Gender

Male Female

Birthdate (mm/dd/yyyy)

Relationship to Head(s) of Household

Name of School Attending

Grade

Resident #2

First Name

Middle Initial

Last Name

Gender

Male Female

Birthdate (mm/dd/yyyy)

Relationship to Head(s) of Household

Name of School Attending

Grade

Resident #3

First Name

Middle Initial

Last Name

Gender

Male Female

Birthdate (mm/dd/yyyy)

Relationship to Head(s) of Household

Name of School Attending

Grade

Resident #4

First Name

Middle Initial

Last Name

Gender

Male Female

Birthdate (mm/dd/yyyy)

Relationship to Head(s) of Household

Name of School Attending

Grade

Resident #5

First Name

Middle Initial

Last Name

Gender

Male Female

Birthdate (mm/dd/yyyy)

Relationship to Head(s) of Household

Name of School Attending

Grade