* Required


Student Information:


Parent/Guardian Information:


If your child becomes ill during the day and needs to leave, please list in order of importance, the names of four adults, including yourself and/or spouse, along with the day time phone numbers. It is understood that those listed have your permission to pick up your child


List the names of all children in the household, including their date of birth, relationship, and current school.




Kindergarten Parent Questionnaire


Prior to entering Kindergarten, my child has been cared for in the following ways. Please check all that apply: (Full-Time: more than 24 hours per week, Part-Time: less than 24 hours per week)

Help us learn more about your child before they start school:

CONSENT FORM FOR MUTUAL EXCHANGE OF INFORMATION REGISTERED WITH ANSONIA

I hereby authorize the mutual exchange of regular and special education (if the student has been identified as a special education student, please include current IEP and evaluations) records regarding the above-named child between this school district and (list schools, physicians, psychologists, hospitals clinics, etc., that have had significant contact with your child). The purpose of this exchange is to assist educational planning, evaluation and/or intervention.

I CERTIFY THAT I AM THE PARENT OF LEGAL GUARDIAN OF THE ABOVE-NAMED CHILD OR THAT I AM THE STUDENT OF MAJORITY AGE AND HAVE THE AUTHORITY TO SIGN THIS RELEASE


Lunch Income Application Form

All schools in Ansonia participate in the Community Eligibility Provision program through the State of Connecticut, which provides free breakfast and lunch to all Ansonia students. However, you can help our school system to potentially receive additional funding by completing the household income form below and signing it. This information is for district use ONLY;this information is confidential and is not shared.

1. Select the total number of people in your household. Be sure to include ALL children and adults, related and unrelated, that live in a single dwelling and share income and expenses.

2. Select the box that represents the range of annual household income. This should include all of the following income sources: work, welfare, child support, alimony, pensions, retirement, Social Security, SSI, VA benefits, child income, or other income. The amount should be BEFORE any deductions for taxes, etc.



***DISCLAIMER***

THESE ITEMS WILL BE REQUIRED AT A LATER DATE VIA APPOINTMENT ONLY

  • Birth Certificate of student
  • ID or License of Parent/Guardian
  • 2 Proofs of Residence (Mortgage or rental agreement and utility bill) from Parent/Guardian
  • Child's Health Assessment form


ELECTRONIC SIGNATURE AGREEMENT: BY TYPING YOUR NAME IN THE BOX BELOW AND CLICKING THE "SUBMIT" BUTTON, YOU ARE SIGNING THIS AGREEMENT ELECTRONICALLY. YOU AGREE YOUR ELECTRONIC SIGNATURE IS HE LEGAL EQUIVALENT OF YOU MANUAL SIGNATURE ON THIS AGREEMENT. WHEN PRESSING "SUBMIT" YOU CONSENT TO BE LEGALLY BOUND BY THIS AGREEMENT'S TERMS AND CONDITIONS.