Intent to Register

Intent to Register for 2017-2018 School Year
Complete this form if you intend to register your child in the Central Community School System for the school year 2017-2018. List only children NOT currently registered in the Central Community School System. A separate form should be completed for each child to be registered. ALL INFORMATION WILL BE KEPT CONFIDENTIAL.

**Please answer questions carefully. What Central school are you registering your child for the 2017-18 school year? Then we need the grade and school your child LAST attended. Before a student is placed in a grade level at a school, previous records must be reviewed.
Parent(s) Name  
 *City St, Zip  
 *  *
Phone #  
Child's Name  
Child's Birthdate  
Child's Gender  
What school are you planning to register your child this 2017-18 school year *  
Grade attended in 2016-2017 school year *  
 *Last School Attended  
Special Needs (what special services does your child receive, if any)  
  Security Check:

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Central Community School System is an equal opportunity employer and does not discriminate on the basis of race, color, national origin, gender, age, or qualified disability. Central Community School System provides equal access to all programs and services without discrimination based on sex, race, creed, religion, color, national origin, age, sexual orientation including gender expression or identity, or any disability. For question or complaints of alleged discrimination, contact the CCSS Title IX/Section 504 Coordinator at
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