KINDERGARTEN Interest Form For School Year 2023-2024

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Please fill out all the information below. Your child will be placed on a call list for one of our Kindergarten Screenings and must be at least 5 years old by August 31, 2023.

This form will place the student on our list and is NOT a registration. When the students name is next on the list, we will contact you to schedule a screening for the student.
Thank you!

Email *

ACUSHNET KINDERGARTEN PROGRAM 2023-2024

Parent / Guardian Name *

Parent / Guardian Email *

Parent Phone Number *

Student First, Middle & Last Name *

Student's Date of Birth *

YYYY

My student wiil be ___ Years old as of AUGUST 31 2023? *

3 Years Old

4 Years Old

5 Years Old

6 Years Old

Other:

Home Address (City, State Zip Code) *

Student's Gender *

Female

Male

Prefer not to say

Other:

Ethnicity: *

Non/Hispanic Latino

Hispanic

Latino

Other:

Primary Language of the Student *

Currently or Previously Enrolled in: *

Preschool

Family Child Care

Early Intervention

Other:

My Child has an IEP or 504 Plan? *

Yes

Required

PHYSICAL DEVELOPMENT - Please check the word that best describes your child's ability in the following areas: *

GOOD

AVERAGE

NEEDS HELP

NOT APPLICABLE

Uses Scissors

Uses Crayons

Uses Pencils

Climbs

Walks

Runs

Hops on One Foot

Jumps

Please check under the word that best describes your child's COMMUNICATION *

GOOD

AVERAGE

NEEDS HELP

NOT APPLICABLE

Uses words to express self

Speaks Clearly

Vocabulary is age-appropriate

Understands Directions

How does your child react to new situations? *

How does your child react when you leave them? *

Please list your child's favorite activities: *

What descriptive words do you use to generally describe your child? *

How do you and your family spend time together? *

My Child has received prior academic / social / emotional testing or evaluations? (Name of test, dates, location) *

Has the student received any of the following?

Speech

Occupational Therapy (OT)

Physical Therapy (PT)

Applied Behavior Analysis (ABA)

Early Intervention

Other:

What language do you use most often with your child? *

What language does your child use most? *

Will you need a translator for school screenings, meetings, etc? *

Yes

Upon submission of this form, I understand that my child will be then placed on the call list for a Preschool screening. I will only be contacted when it is my child's turn to be screened. I understand that my child may not be placed this school year due to the heavy volume on the call list. *

Yes, I understand and would like my child added to the list.

No, I do not agree and would not like to be added to the list.

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