Greenwood School District Census Form

ALL INFORMATION IS CONFIDENTIAL

Please review instructions before completing
Online Instructions

If you have any questions, please call the district at 717-589-3117 ext. 1300.
Greenwood School District Census Office
405 E. Sunbury Street
Millerstown, PA 17062

Note: Options for Completing:
1) No Change - Check box, Fill in Residence # and Name at bottom of form
2) Changes - Check box, Fill in Residence #, Name at bottom, and areas where changes are needed.
3) New Information - Check box, Fill in complete form.

Enter your Residence # from the top left box of the form you received in the mail - All CAPS. Do NOT enter your mailing address here!

Residence #

Residence/Street Address

Street:
Apt #:		City:
State:		Zip:

THIS SECTION FOR ADULTS 18 AND OVER

THIS SECTION FOR CHILDREN UNDER 18 OR STILL IN HIGH SCHOOL

Name of Child (Last, First, Middle Initial)	Delete Name (Put an X to Delete Name)	Sex	Birthdate (00/00/0000)	Name of School (For This Year)	Grade
1. Last Name: First Name: MI:
2. Last Name: First Name: MI:
3. Last Name: First Name: MI:
4. Last Name: First Name: MI:
5. Last Name: First Name: MI:
6. Last Name: First Name: MI:
7. Last Name: First Name: MI:
8. Last Name: First Name: MI:
9. Last Name: First Name: MI:
10. Last Name: First Name: MI:

If you expect to move prior to July 1, please note date and new address:	Date:
	Street:
	Apt:
	City/State/Zip:

PROPERTY STATUS Check one of the following Own Rent

Name of Adult
(Last, First, Middle Initial)

Delete Name
(Put an X to
Delete Name)

Birthdate
(00/00/0000)

Relationship

Employment Status

Head of Household
(Please select
only one)

1. Last Name:
First Name: MI:

2. Last Name:
First Name: MI:

3. Last Name:
First Name: MI:

4. Last Name:
First Name: MI:

5. Last Name:
First Name: MI:

I verify that the information above is complete and accurate:
Full Name:
Date:	12/13/2019
Telephone Number:
	Must check a box 1,2 or 3 at top of form before submitting.

If you have any questions, please call the district at 717-589-3117 ext. 1300.

If you experience any trouble with the form, please contact us at info@dhfassociates.com