Middletown Area School District Census Form

Please review instructions before completing Online Instructions

If you have any questions, please call the census office at 717-948-3300 Ext 1013.
Middletown Area School District Census Office
55 W. Water Street
Middletown, PA 17057

If you experience any trouble with the form, please contact us at [email protected]

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

Enter your Dwelling # from the top left box of the form you received in the mail.

Dwelling #
*If you do not have your Dwelling #, please contact us.

Residence/Street Address- Please Enter Street Address
Street:
Apt #: City:
State: Zip:
THIS SECTION FOR ADULTS 18 AND OVER
Name of Adult
(Last, First, Middle Initial)		 Delete Name
(Put an X to
Delete Name)		 Gender Birthdate
(00/00/0000)
Status
1 - Single
2 - Married
3 - Widow
 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:
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)		 Gender Birthdate
(00/00/0000)		 School Currently Attending
Code  |  Name of school
(enter code from instructions) 		Grade Current
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
ALL INFORMATION IS CONFIDENTIAL
I verify that the information above is complete and accurate:
Full Name:
Date:12/2/2025
Telephone Number:
 
Must check a box 1,2 or 3 at top of form before submitting.