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Kindergarten Intake Form
Please complete and submit the Pre-Registration Form
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* Indicates required question
Email
*
Your email
Child's Legal First and Last Name
*
Your answer
Child's Gender
*
Female
Male
Unspecified
Child's Date of Birth
*
MM
/
DD
/
YYYY
Legal Guardian #1 Full Name
*
Your answer
Legal Guardian #1 Phone Number
*
Your answer
Legal Guardian #2 Full Name
Your answer
Legal Guardian #2 Phone Number
Your answer
Do both legal guardians live in the same household?
*
No
Yes
Mailing address of child's Primary Residence (include city & postal code)
*
Your answer
Physical 911 address of child's Primary Residence
*
Your answer
Do you require bussing?
*
Yes
No
Has your child had any of the following assessments? (check all applicable)
Speech & Language
Psychiatric/Psychological
Physical Therapy/Occupational Therapy
Hearing
Vision
Other:
Physician(s) involved in care (include phone number)
Your answer
Agencies involved with child/family (i.e. ACFS, FSCD, Early Intervention, etc.) please include contact information.
Your answer
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