Today's Date: 
 
Names of Parents or Guardians and all Resident Taxpayers (please list homeowner or lease holder first):
Name Home Phone Cell Phone
Name Home Phone Cell Phone
Name Home Phone Cell Phone
 
Current Address:
Subdivision/School/District
House Number Street Name P.O. Box (Both required if applicable)
City State Zip
 
Do you rent or own the home?    
 
LEGAL NAME OF CHILDREN LIVING IN HOME GRADE & SCHOOL ENTERING PLACE OF BIRTH DATE OF BIRTH GENDER
*Hispanic/Latino: Yes No
*Ethnic Background:  American Indian/Alaska Native  Asian  Black/African American
 Hawaiian/Pacific Islander  White/Caucasian
*Please note ethnicity is not required by state statue, however, it is required by the Nebraska Department of Education and is gathered in advance to fulfill that requirement.