Kindergarten Registration Form

Kindergarten Registration Form

Merced River School District
Child Information
Childs LEGAL Name*

First NameMiddle NameLast Name
Birthdate*

MonthDayYear
Date
Sex*
Child Lives with*
Living Conditions*
Last School Attended:*
Last school's Phone Number*

Area CodePhone Number
Last Date attended*

MonthDayYear
Date
Was the child born in the U.S.?*

YesNo
Child's birthplace*
Child's Ethnicity*
Does Child have any Siblings?*

YesNo
Siblings name

First NameLast Name
Race

(Please select up to five racial categories) The above question is about Ethnicity, not race. No matter what you selected above, please continue to answer the following by marking one or more boxes to indicate what you consider your race to be.
Childs Race*

American Indian or Alaskan Native (Persons having origins in any of the original people of North, Central and South Americas)African AmericanChineseJapaneseKoreanVietnameseAsian IndianLaotianCambodianHmongOther AsianHawaiianGuamanianSomoanTahitianOther Pacific IslanderWhite (Persons having origins in any of the original peoples of Europe, North Africa or Middle East)
Home Language Survey
What Language did your son / daughter learn when he / she first began to talk?
Select:*

EnglishSpanishOther
Language*
What Language does your son / daughter most frequently use at home?
Select:*

EnglishSpanishOther
What Language do you use most frequently to speak to your son / daughter?
Select:*

EnglishSpanishOther
Name the Language most often spoken by the adults at home:
Select:*

EnglishSpanishOther
Parent Education Level*

Not a high school graduateHigh school graduateSome college (Includes AA)College graduateGraduate school / Postgraduate training
Prefered Parent Contact
Parent Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is Mail Address same?*

YesNo
Mailing Address - If different from above*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent Information
Mother's Name*

First NameLast Name
Mother's Employer*
Mother's Email
example@example.com
Mother's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father's Name*

First NameLast Name
Father's Employer*
Father's Email*
example@example.com
Same address as the other parent?*

YesNo
Father's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Health Information
Family Physician:*
Family Dentist:*
Health Plan:*
Allergies:*
If non type N/A
Secondary Emergency Contacts:

Persons who act for parents when parents cannot be reached. These persons should be able to provide transportation. *TWO NAMES MUST BE PROVIDED*
Emergency Contact 01
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship to child*
Emergency Contact 02
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship to child*
Emergency Contact 03

*OPTIONAL
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship to child
What Special services has your child received?*

Resource (RSP)Gifted (GATE)Medical Health PlanSpecial Day Class (SDC)Remedial MathEnglish Language Development (ELD)Speech/LanguageRemedial Reading504 Accomodation PlanCounselingNone of the above
Has your child been expelled or in process of being expelled from any school?
YesNo
What school?*

Name of schoolLocationDate
Acknowledgment
I agree that if both or all contacts do not answer District may contact appropriate Authorities in emergency cases (Police, Ambulance etc.)*

YesNo
I agree that all the above information is correct and accurate to the best of my knowldge.
Signature*

Clear
Should be Empty:

Kindergarten Registration Form

Child Information

Race

Home Language Survey

Prefered Parent Contact

Parent Information

Health Information

Emergency Contact 01

Emergency Contact 02

Emergency Contact 03

Acknowledgment