Family Information

Prekindergarten Enrollment Form
Student Enrollment Form

	First Name	Middle Name	Last Name	Date of Birth	Gender	Birth Place
Student

Student Information*

	Y/N	If yes, where?
Has your child participated in Early Childhood Screening?

Special Services Information*

	Y/N
Has your child received English Language or Bilingual Services?
Is an interpreter needed?
Is your child toilet trained?

	Y/N
Does your child currently have an IEP (Individualized Education Plan) or a 504 Plan?

Medical Information

Health information will be shared with our Licensed School Nurse who will call to follow-up, if necessary. If your child received their immunizations outside of Minnesota, please provide us with a copy. If you choose not to immunize your child due to medical or conscientious objection, we need the notarized statement on file here at school.

	Y/N	If yes, please explain
Does your child need to take any medications while at school? (If yes, please indicate child's name, medication, dosage, and time of day taken)

	Y/N	If yes, please explain
Does your child have any health conditions such as diabetes, severe allergies, asthma, or seizures?

	Y/N
Is your child up-to-date with immunizations?

Primary Parent/Guardian Information

Person(s) with whom the student resides.

Parent/Guardian Information*

	First Name	Last Name	Date of Birth	Gender	Relationship to Child	Email Address	Cell Phone	Work Phone
Parent/Guardian 1
Parent/Guardian 2

Address*

	Street Address	City	State	Zip
Home Address
Mailing Address

Do the parent/guardians listed about have full legal rights?*

	Yes	No	Other
Parent/Guardian 1
Parent/Guardian 2

Emergency Contacts

The following person(s) are allowed to pick up my child in my absence.

	First Name	Last Name	Home Phone	Cell Phone	Work Phone	Relationship to Student	Can Student be Release to this Person?
Emergency Contact 1
Emergency Contact 2

Family Information

	Y/N
Are there any "No Contact" or other legal orders in effect regarding your student(s)? *If yes, you must provide a copy.
Has your family moved within the past 36 months as a result of seasonal or temporary employment of parent in agricultural work?
Do you currently reside with another family, or person other than family, or in a temporary housing facility?
Is this student in Foster Care?
Is this student a military connected youth?
Does this student have an actively deployed parent?