Minersville School Kindergarten Registration 2020-2021

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Please register your student for kindergarten for the school year 2020-2021. We will request immunization and state issued birth certificates at a later time.

Student Name (First, Middle, Last) *

Gender *

Female

Male

Date of Birth (Month/Day/Year) *

YYYY

Place of Birth (City, State) *

Has the student ever attended school in the State of Utah? *

Yes

If the student has attended school in the State of Utah, where and when?

Physical address of Student (including City, State, Zip)

P.O. Box # *

Main Phone Number *

Ethnicity (select one) *

Non-Hispanic

Hispanic

Required

Race (select all that apply *

American Indian

Pacific Islander

Asian

African American

Caucasian

Other

Required

Mother *

Custodial

Non-custodial

Protective Order

Required

Motherś Name (First and Last Name) *

Motherś Email Address: *

Motherś Physical Address (Physical address including the City, State, Zip) *

PO Box # *

Motherś Phone Numbers where you can be reached. Please indicate if cell, residential or work) *

Father *

Custodial

Non-Custodial

Protective Order

Required

Fatherś Name (First and Last Name) *

Fatherś Email Address *

Fatherś Physical Address (including City, State and Zip) *

Fatherś Phone Numbers where you can be reached. Please indicate if cell, residential or work) *

Brothers and Sisters - please list names and dates of birth *

Emergency Contact 1 (Someone other than you we can contact if your child is sick and we cannot get a hold of you) Please put full name and phone number *

Emergency Contact 2 (Someone other than you we can contact if your child is sick and we cannot get a hold of you) Please put full name and phone number

If you are a custodial guardian but put your information under mother or father, please select yes below

Yes

Student's Country of Birth *

If the student is not from the U.S., indicate the date of entry into the U.S.

YYYY

Years in the U.S.

Less than 1 year

1 year

2 years

3 years

More than 3 years

Clear selection

Number of Complete years enrolled in U.S.

Which language does your child most frequently speak at home? *

Which language do adults in your home most frequently use when speaking with your child? *

Which language(s) does your child currently understand and speak? *

Which language(s) does your student read and write? *

Name and Phone Number of Family Physician: *

Is the student under medical care for any health problems? Please answer yes or no. If yes, please explain. *

Are there any concerns you would like to share with the school nurse? Please answer yes or no. If yes, please explain. *

Is the student taking any medications? Please answer yes or no. If yes, please give name of medication, dosage and reason. *

Does the student have any of the following conditions? (Click all that apply) *

Epilepsy (Seizures)

Heart Problems

Bone/Joint Problems

Food Allergies

Medication Allergies

Diabetes

History of Asthma

Kidney/Bladder Problems

Frequent Ear Infections

Hearing Problems

Speech Problems

Wear glasses/contacts

Not applicable

Required

If you checked any of the above conditions, please provide more information about the condition such as limitations, inhaler, date of last seizure, etc?

Other physical problems or medical limitations or other concerns? *

Submit

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