Edwardsburg Primary Kindergarten Registration 2023-2024

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Student Information:

Email *

Student's Legal Last Name *

Student's Legal First Name *

Student's Middle Name *

Student's Birth Date *

YYYY

Student's Gender *

Female

Male

Student's Preferred Name

STUDENT PRIMARY HOUSEHOLD RESIDENCE

Student's Street Address - Apt/Lot # *

P.O. Box

City *

State *

Zip *

County *

Home Phone or Primary Contact Phone- (Please use this format XXX-XXX-XXXX) *

Current Living Arrangement: *

In permanent housing

In a shelter

In a hotel/motel

In a car, park, bus, train, or campsite

In a foster home

Unaccompanied youth

With another family or person due to loss of housing or as a result of economic hardship

Other temporary living situation (describe below):

Please describe other living situation:

LEGAL PARENT(S) OR GUARDIAN(S) LIVING IN PRIMARY HOUSEHOLD

Parent/Guardian #1 - First Name *

Parent/Guardian #1 - Last Name *

Parent/Guardian #1 Relationship to Student: *

Mother

Father

Stepmother

Stepfather

Grandmother

Grandfather

Court Guardian

Foster Mother

Foster Father

Other

Other:

Parent/Guardian #1 Cell Phone (XXX-XXX-XXXX) *

Parent/Guardian #1 Email Address: *

Parent/Guardian #1 Address / City / State / Zip (If different from Student)

Parent/Guardian #1 Employer Name:

Parent/Guardian #1 Employer Phone (XXX-XXX-XXXX):

Parent/Guardian #2 - First Name

Parent/Guardian #2 - Last Name

Parent/Guardian #2 Relationship to Student:

Mother

Father

Stepmother

Stepfather

Grandmother

Grandfather

Court Guardian

Foster Mother

Foster Father

Other

Clear selection

Parent/Guardian #2 Cell Phone (XXX-XXX-XXXX)

Parent/Guardian #2 Email Address

Parent/Guardian #2 Address / City / State / Zip (If different from Student)

Parent/Guardian #2 Employer Name:

Parent/Guardian #2 Employer Phone (XXX-XXX-XXXX):

Please answer both parts of the Ethnicity and Race sections. Regardless of what you select for Ethnicity, please select one or more boxes to indicate what you consider your student’s race to be. If either part is not answered, the U.S. Department of Education requires the school district to supply an answer on your behalf

ETHNICITY & RACE / CITIZENSHIP / HOME LANGUAGE

Ethnicity: Is this student Hispanic/Latino? (Choose only one) (A person of Cuban, Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture or origin, regardless of race.) *

Yes

Race: (Choose one or more) *

American Indian or Alaska Native

Asian

Black or African American

Pacific Islander

White

Required

Is student a U.S. citizen? *

Yes

If no, in what country is student a citizen?

First year in USA? *

Yes

Is your child’s native tongue a language other than English? *

Yes

Is the primary language used in your child’s home or environment a language other than English? *

Yes

If yes, what is the language? (Sections 380.1152 ‐ 380.1157 of the School Code of 1995)

HEALTH/MEDICAL INFORMATION

Please check all that apply: *

No known medical problems

ADD/ADHD

asthma

bleeding disorder

diabetes

hayfever

headaches

hearing impaired

seizures

bee sting allergy

food allergy

medication allergy

other allergy

bronchitis or breathing problems

eczema or skin conditions

frequent ear, throat, sinus infections

heart murmur

other heart problems (please provide additional comments)

other health concerns (please provide additional comments

Required

Additional comments from Health/Medical Information from above:

Physical Limitations:

Physician Name:

Physician Phone:

Medications:

NOTE: All medications taken at school must follow Michigan Law, which requires schools to have a written physician’s order and parent/guardian authorization. Medication Authorization Forms are available at each school or on the district website.

Is medication administered at school?

Yes

Clear selection

KINDERGARTEN PARENT SURVEY

Are you an Edwardsburg School District Resident? *

Yes

If no, what school district will you be coming from:

Berrien Springs

Brandywine

Buchanan

Cassopolis

Constantine

Dowagiac

Galien

Marcellus

Niles

Three Rivers

White Pigeon

Out of State

Other

Clear selection

Did your child attend preschool? *

Yes

Where did your child attend preschool?

Does your child have daycare experience? *

Yes

Where did your child attend daycare?

Special Education Services: My child receives special services through an IEP (Individualized Education Plan): *

Yes

Other:

If yes, please indicate below

Speech Therapy

Special Education Academic Services

Behavioral Support

Occupational Therapy

Physical Therapy

Other:

Clear selection

My child is receiving special services from:

Lewis Cass ISD

Berrien RESA

VanBuren ISD

Other

Clear selection

My child does not receive formal special education services, but I have concerns regarding:

Speech Producation

Fine Motor Skills - example writing, cutting, coloring, etc...

Gross Motor Skills - example walking, jumping, running, etc...

Behavior/Peer Relationships

Other:

Clear selection

If you indicated any concerns above, please explain below.

EDUCATIONAL PROGRAM PLACEMENT

Program requests from Kindergarten Registration to June 1st will be assigned a program by lottery only. After June 1st, assignments will be made only to those programs that have open seats available. Indicate your preference for the program placement by marking 1 through 4. (1 is first preference, 4 is last preference) I understand that all documentation, county issued birth certificate, proof of residency and completed immunization record, must be submitted before my enrollment is considered complete.

#Program Placement

Single Grade

Multiage

Looping

No Preference

First Choice

Second Choice

Third Choice

Fourth Choice

Clear selection

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