Student Information:

First Namerequired

Middle Namerequired

Last Namerequired

Agerequired

Addressrequired

What grade are you registering this child for?required

D.O.B (mm/dd/yyyy)required

Place of Birthrequired

Child is:*

M F

U.S. Citizen*

Yes No

If no, list citizenshiprequired

Does this child have Health Insurance?*

Yes No

Is your child's parent or guardian a member of the Armed Forces on active duty or serves on full-time National Guard duty?*

Yes No

Does your child have any medical conditions such as severe reactions to insect bites, medications, or food which require emergency treatment?*

Yes No

Doctor Name

Doctor Phone #

Student lives with:*

Both Parents Mother Father Stepmother Stepfather Other

Parent/Guardian Information:

Mother's Name

Address

Home Telephone

Cell Phone

Employer

Work Phone

Email

Father's Name

Address

Home Telephone

Cell Phone

Employer

Work Phone

Email

Guardian's Name

Address

Home Telephone

Cell Phone

Employer

Work Phone

Email

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

1) Namerequired

1) Relationshiprequired

1) Phone Numberrequired

2) Namerequired

2) Relationshiprequired

2) Phone Numberrequired

3) Namerequired

3) Relationshiprequired

3) Phone Numberrequired

4) Name

4) Relationship

4) Phone Number

Has your child been a student in the Ansonia Public Schools before?*

Yes No

If yes, which school?required

List dates of attendance:required

What is the most recent school your child has attended?required

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

Name

Date of Birth

Relationship

Current School

Name

Date of Birth

Relationship

Current School

Name

Date of Birth

Relationship

Current School

Name

Date of Birth

Relationship

Current School

What is the primary language used in the home, reardless of the language spoke by the student?required

What is the language most often spoken by the student?required

What is the language the student first learned to speak?required

Has your child been educated in the United States for 3 years or more?*

Yes No

Has your child received/attended any special services/programs? Please select all that apply:

Speech and Language Tutoring (Title 1) English as a Second Language/Bilingual Academically talented Other

Does your child have an IEP?*

Yes No

Does your child have a 504 plan?*

Yes No

(For incoming Kindergarten-Grade 3 students only: all other can move to the next section)Did your child attend a Head Start program, private nursery/preschool, licensed day care center, public preschool program, or family day care?

Yes No

Is this child Hispanic/Latino?*

Yes No

What is the child's race? (check one or more, even if you answered yes to the Hispanic/Latino question)*

American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White

Kindergarten Parent Questionnaire

Student First Namerequired

Middle Namerequired

Last Namerequired

My child speaks and understands English*

Yes No Some

What language did your child learn when first beginning to talk?required

What language does your child use most frequently at home?required

What language do you use most frequently to speak to your child?required

What language is most often spoken by the adults at home?required

Has your child been involved in any organized activites? (Please check all that apply)

Sports (e.g., skating lessons, swimming, soccer, gymnastics) Music Library Programs Community Programs Other

Please explain:

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)

Full-Time

Child Care Center Nursery School Home Child Care Care With Relative

Part-Time

Child Care Center Nursery School Home Child Care Care With Relative

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

My child plays cooperatively with other children*

Yes No

My child can follow a 1-step direction (e.g.g, please get your shoes)*

Yes No

My child is*

Left Handed Right Handed Mixed or Preference Unclear

Can your child draw recognizable pictures*

Yes No

Can your child print all of his/her name?*

Yes No

Does your child show interest in playing with others?*

Yes No

Does your child play successfully with others?*

Yes No

Can your child name the colors?*

Yes No

Can your child count objects up to 5?*

Yes No

Does your child have the ability to follow 2-3 part directions? (ex: "Go to your room, get your shoes and put them on")*

Yes No

Can your child listen to a story from beginning to end?*

Yes No

Can your child recognize his/her name in print?*

Yes No

Is your child usually cooperative?*

Yes No

My chid uses pencils/crayons/markers:*

Often Occasionally Never

My child used scissors:*

Often Occasionally Never

My child is able to manage how they feel and tell about his/her feelings:*

Often Occasionally Never

Are there any situations in which your child becomes particularly excitable, upset, frightened or angry?*

Yes No

Please provide examples:required

Has your child experienced any significant changes in his/her family life in the past? (e.g., death, separation, birth of a baby, family illness)*

Yes No

Please provide examples:required

Please share with us any other concerns, comments, questions or any other information you vbelieve will help us work together so that you and your child have a positive start and experience at our school:

Electronic Signature:required