22-23 Preschool Student Enrollment Form
Woodford County Special Education Association
Resident School District
*
Please Select
#1 Metamora Grade School
#2 Riverview Grade School
#6 Fieldcrest Primary
#21 Lowpoint Washburn
#60 Roanoke Benson
#69 Germantown Hills
#140 Congerville-Eureka-Goodfield
Attending School District
*
Please Select
#1 Metamora Grade School
#2 Riverview Grade School
#6 Fieldcrest Primary
#21 Lowpoint Washburn
WCSEA Intensive ECE
Student Information
Name
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Date
Birth Place (City)
Gender
Please Select
Male
Female
Ethnicity
Please Select
American Indian
Asian Pacific
Black/African American
Hispanic
White
Multiracial
Students Residental Street Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred emal address to reach the family
*
example@example.com
List legal Guardian(s) and relationship to the student
*
Mother/Guardian #1 Contact Information
Mother/Guardian #1 Information
*
First Name
Last Name
Mother/Guardian #1 Information
Street Address (If different from student)
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Place of Employment
Maiden Name
*
Father/Guardian #2 Contact Information
If different than Mother/Guardian #1
Father/Guardian #2 Information
*
First Name
Last Name
Father/Guardian #2 Information
Street Address (if different from student)
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Place of Employment
Babysitter Information - (if applicable)
Baby Sitter Information - if applicable
Name of Babysitter
Street Address
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
List the name and relationship of people picking up your child from school (if applicable)
Emergency Contact Information - (list local people)
List 2 reliable local contacts wiht working phone numbers in the event of a student emergency and you are unable to be reached.
Emergency Contact #1
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Emergency Contact #2
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Medical Information
In the event that no one can be reached and immediate medical attention is required, the school district will contact medical personnel and/or transprot to the hospital.
Preferred Hospital in the event of a student emergency
*
Primary cary physician in the event of a student emergency
*
Any prescription medication or medical procedures to be administered at the school will require a current dated prescription and current dated written instructons from the ordering licensed physician. In the event of a food allergy, severe environmental allergy (ie. bee venom) or seizures, you will need to have additional information sent to the school from your child's physician prior to your child starting school.
Medical Diagnosis
Current Medication
Information helpful for school staff:
Signature
*
Clear
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: