Pequea Valley School District Census Form

Please review instructions before completing
Online Instructions

If you have any questions, please call the district at 717-768-5530.
Pequea Valley School District
166 S. New Holland Road
PO Box 130
Kinzers, PA 17535

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 the Residence# from the top of the form you received in the mail only. NOTE: Do NOT enter your mailing address here!
Residence #


Residence/Street Address
Street:
Apt #: City:
State: Zip:




THIS SECTION FOR ADULTS 18 AND OVER
Name of Adult
(Last, First, Middle Initial)
Birthdate
(00/00/0000)
Gender
 
Race
 
Employment
Status
Employer
Zip Code
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:

THIS SECTION FOR CHILDREN UNDER 18 OR STILL IN HIGH SCHOOL
Name of Child
(Last, First, Middle Initial)
Birthdate
(00/00/0000)
Gender Race Grade
(for Sept
next year)
School
Code
Name of School
(for Sept next year)
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:

CHILD DISABILITIES
Have any of the children above been diagnosed with disabilities?
Yes     No
INTERNET
What is your internet connection speed?
Moderate (i.e., 56k Dialup)
High (i.e., DSL/Cable)
Don't Know

PROPERTY STATUS
Check one of the following Own   Rent

IF OWN:
Owner Occupied
Tenant Occupied
Vacant

Residence Type
IF RENT:
Landlord's Name:
Landlord's Phone#:
Street/Apt #:
City/State/Zip:

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

ALL INFORMATION IS CONFIDENTIAL

I verify that the information above is complete and accurate:
Full Name:
Date:12/15/2018
Telephone Number:   Check if Unlisted
 


If you have any questions, please call the district at 717-768-5530.
Pequea Valley School District
166 S. New Holland Road
PO Box 130
Kinzers, PA 17535

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

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