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Pre-K and Kindergarten Registration 2022
Pre-K Registration: Please register your child for the upcoming school year. Your child needs to be 4 years old before October 15, 2022
Kindergarten Registration: Please register your child for the upcoming school year if they are not already registered in our Pre-K program. Your child needs to be 5 years old before October 15, 2022
In addition to registering online we need to following documentation dropped or mailed to the school: Birth Certificate, Proof of Residency, Any Court Documents, and IEP's.
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Email
*
Your email
Please indicate if this form is being filled out for a Pre-K or Kindergarten student.
Pre-K
Kindergarten
Child's Name
Your answer
Age
Your answer
Sex
Male
Female
Date of Birth
MM
/
DD
/
YYYY
Mailing Address
Your answer
Physical Address
Your answer
Phone #
Your answer
Student's Ethnicity
Caucasian/White
Hispanic or Lantino
Asian
Native Hawaiian/ Other Pacific Island
Native American/ Alaskan Native
Bi-racial/Multi-racial
African American
Other
Mother's Name
Your answer
Mother's Address ( if different from above)
Your answer
Mother's Home Phone
Your answer
Mother's Cell Phone
Your answer
Mother's E-Mail Address
Your answer
Mother's Place of Employment
Your answer
Mother's Work Phone
Your answer
Father's Name
Your answer
Father's Address ( if different from above)
Your answer
Father's Home Phone
Your answer
Father's Cell Phone
Your answer
Father's E-mail Address
Your answer
Father's Place of Employment
Your answer
Father's Work Phone
Your answer
Parents live:
together
separated
divorced
deceased
Other:
Clear selection
Step-mother's Name (if applicable)
Your answer
Step-father's Name (if applicable)
Your answer
Do you have legal custody of the student?
Yes
No
Clear selection
Does this student reside with you?
Yes
No
Clear selection
If no, where does the student reside:
Your answer
Is this student in Foster Care?
Yes
No
Clear selection
Number of family members in the home:
Your answer
Name of brothers and sisters : (indicate Sex and Age of each child)
Your answer
Names of any others living at home (indicate relationship)
Your answer
Is your child receiving any special needs services with Child DevelopmentServices (CDS)?
Yes
No
Clear selection
If yes, in what area are they receiving services?
Speech
Occupational Therapy
Other
Are any siblings receiving special needs services in school?
Yes
No
Clear selection
Does your child have an IEP?
Yes
No
Clear selection
Name of child's doctor
Your answer
Doctor's address
Your answer
General Health of child
Your answer
Important and/or persistent illnesses, injuries, accidents, operations, ear infections, allergies, colds, fevers, convulsions: (please indicate condition, age, treatment, and if they were hospitalized)
Your answer
Has your child had vision checked?
Yes
No
Clear selection
If so, by whom?
Your answer
Any special medical examinations? (i.e. neurological, ENT, etc.) (indicate date, by whom, specialty, and finding)
Your answer
Any routine medication? For what purpose?
Your answer
Any other medical conditions (i.e braces, contact lenses, etc.)
Your answer
Did either parent have any learning or behavior difficulties in school?
Yes
No
Other:
Clear selection
Any concerns about speech or listening?
Yes
No
Does child enjoy listening to stories?
Yes
No
Clear selection
At what age did your child: react to noise
Your answer
At what age did your child: babble
Your answer
At what age did your child: react to voice
Your answer
At what age did your child: say first word
Your answer
At what age did your child: put a few words together
Your answer
Is the child curious to find out about people, places, and things?
Yes
No
Clear selection
Is the child’s speech understandable by family members?
Yes
No
Other:
Clear selection
Is the child’s speech understandable by neighbors?
Yes
No
Other:
Clear selection
Is the child’s speech understandable by friends?
Yes
No
Other:
Clear selection
Does the child demonstrate the following: difficulty learning songs, rhymes
Always
Sometimes
Never
Does the child demonstrate the following: difficulty with repetition
Always
Sometimes
Never
Does the child demonstrate the following: demonstrates understanding of verbal instructions
Always
Sometimes
Never
Clear selection
Does the child demonstrate the following: responds to only part of a direction
Always
Sometimes
Never
Clear selection
Does the child demonstrate the following: uses visual clues to understand directions
Always
Sometimes
Never
Clear selection
Does the child demonstrate the following: talks very little
Always
Sometimes
Never
Clear selection
Does the child demonstrate the following: unwilling to talk with some people
Always
Sometimes
Never
Does the child demonstrate the following: uses few words in communicating
Always
Sometimes
Never
Does the child demonstrate the following: doesn’t know labels of common objects (i.e. spoon, bottle, light, door)
Always
Sometimes
Never
Clear selection
Does the child demonstrate the following: “talks around” the topic to tell a story
Always
Sometimes
Never
Clear selection
Does the child demonstrate the following: order of words seem confused
Always
Sometimes
Never
What do you enjoy doing with your child?
Your answer
How do you handle upsetting situations? (i.e. discipline)
Your answer
Please list any concern or questions you may have about your child entering school.
Your answer
Transportation Information
My child will not be riding the bus
My child will be riding the bus
Clear selection
My child will get off the bus Monday through Friday at the following address
Your answer
Signature of person filling out this form and relationship to child
Your answer
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