Fillable Poudre School District Early Childhood Programs Data Change (Poudre School District)

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Poudre School District Early Childhood Programs Data Change (Poudre School District)

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The Poudre School District Early Childhood Programs Data Change (Poudre School District) form is 2 pages long and contains:

  • 1 signature
  • 63 check-boxes
  • 72 other fields

Country of origin: US
File type: PDF

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Poudre School District Early Childhood Programs
Data Change Form
Student Name: _________________________________________________________________________ ID: _____________
Parents/Guardian: _______________________________________________________________________________________
Teacher: _____________________________________Classroom Location: _________________________
New Address Information (must provide proof of address):
Home Address: _________________________________________________________________________________________
This change of address results in the family living in: (Please choose one of the following)
____ a shelter,
____ a motel/hotel,
____ temporarily with more than one family because of economic hardship
____ regular housing (apartment, house, mobile home, etc.),
____ other please explain: ____________________________________________________________________
Is student currently receiving transportation? _____ Yes ____ No
Phone Number Change:
Work Phone: _______________________________
Home Phone: ________________________________
Change Additional
Change Additional
Mother
Father
Mother’s Cell Phone: __________________________
Change Additional
Father’s Cell Phone: ________________________
Change Additional
Emergency Contact Information Change:
ADD Emergency Contact
_____________________________________________________________________________________________________
Name Relationship to Student Home Phone Cell Phone Contact for Emergency? Release to?
______________________________________________________________________________________________________
Name Relationship to Student Home Phone Cell Phone Contact for Emergency? Release to?
REMOVE Emergency Contact
______________________________________________________________________________________________________
Name Relationship to Child Home Phone Cell Phone
______________________________________________________________________________________________________
Name Relationship to Child Home Phone Cell Phone
For Custody Changes- Please fill out other side of this form!
Additional Comments/Changes:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
____________________________________________________________________________________
Parent/Guardian Signature Date Phone
Early Childhood Staff Use Only: ☐ Updated PIR
Change Verified by: ___________________ ☐ Updated Nighttime Residence
Changes made to Child Plus (date): ______________ Initials: ____________________ ☐ Updated Neighborhood School
Fax to Fullana Office 490-3134
click to sign
signature
click to edit
New Guardian Information (must provide proof of address and copies of official custody paperwork):
Guardian #1 Name:._____________________________________________________________________________________
Guardian #1 Date of Birth: Relationship to Child:
Guardian #1 Race(please circle): American Indian/Alaskan Asian Black/African American Native Hawaiian/Pacific Islander White
Do you consider your ethnicity to be Latino or Hispanic? _____ Yes ____ No
Guardian #1 email:
Guardian #1 Last Grade Completed (please circle):
Bachelor or Above Associate’s Degree Trade School Post High School High School Diploma GED No Diploma
Guardian #1 Current Employment Status (please circle):
Full-time Part-time Seasonal Unemployed Student Self-employed Stay-at-home Retired/Disabled
Guardian #2 Name:._____________________________________________________________________________________
Guardian #2 Date of Birth: Relationship to Child:
Guardian #2 Race(please circle): American Indian/Alaskan Asian Black/African American Native Hawaiian/Pacific Islander White
Do you consider your ethnicity to be Latino or Hispanic? _____ Yes ____ No
Guardian #2 email:
Guardian #2 Last Grade Completed (please circle):
Bachelor or Above Associate’s Degree Trade School Post High School High School Diploma GED No Diploma
Guardian #2 Current Employment Status (please circle):
Full-time Part-time Seasonal Unemployed Student Self-employed Stay-at-home Retired/Disabled
Are there protective orders? _____ Yes ____ No If so, please provide a copy.
Please list all living in the household:
Full Name
Relationship to child
Date of Birth
School (if applicable)
Financially supported by
guardian? (Y/N)
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Poudre School District Early Childhood Programs Data Change (Poudre School District)

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Completed 14 June 2021

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