Preschool Enrollment Form
Student Name:
*
First Name
Middle Name
Last Name
Student Date of Birth:
*
ex: 01/01/1999
Student Social Security Number:
*
ex: 555-55-5555
Does this student have an IEP?
*
Please Select
Yes
No
Ethnicity?
*
Please Select
White
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
Hispanic
Gender assigned at birth:
*
Please Select
Male
Femal
Does this student have any allergies or other health concerns we should be made aware of?
*
Please Select
Yes
No
If you answered "yes" to the above question, please explain below:
Home Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please list the parent/guardians first and last name(s) followed by their contact number.
*
ex: John Doe 888-555-1234
Please provide a frequently checked email address for the parent/guardians.
*
example@example.com
Please list the parent/guardians name followed by their employer and employer contact number:
*
ex: John - Evergy - 888-555-5959
Please list the names, relationship to student and phone numbers of EMERGENCY contacts for your student if the district is unable to reach the parent/guardian.
*
ex: Julie Doe - grandmother - 888-555-8745
If you would like for your student to utilize bus route services, please select the bus route they will be using below.
*
Please Select
Gridley - AM
LeRoy - PM
No bus route needed
Please list the name of your health insurance provider along with the policy number. The district would also appreciate a copy of your insurance card to have on file. Incomplete information will not be accepted.
*
ex: BCBS - XYZ123456
Preferred Hospital Name:
*
ex: Coffey County Hospital
Preferred Physicians name and phone number:
*
ex: Dr. Downs - 888-555-5235
Liability of Medical Expenses Waiver: I give permission for my children to participate in field trips and other activities authorized by USD 245. Further, I give my legal consent and authorize any representative of USD 245 to authorize emergency medical treatment, including any necessary surgery or hospitalization, for my child(ren) listed above for any injury or illness of and emergency nature he/she incurred while participating in the field trip or other activity by any physician or dentist in accordance with the provisions of the Kansas Healing Arts Act, K.S.A. 650-2801 and any hospital.
*
Please Select
Yes
No
Annual Notice of Authorized Student Data Disclosures: I give permission for USD 245 to post on the district website and the district Facebook page information about my child(ren) including student articles, photos, stories, and information on student life submitted by teachers, coaches, newspaper and yearbook staff. Students will be identified by first and last name all USD 245 schools. (Staff periodically submit articles and pictures to the local Newspapers, pictures and /or names may appear in the newspaper without parent consent.
*
Please Select
Yes
No
Kansas regulations now require that district provide all parents with notice of our written policies regarding Emergency Safety Interventions (“ESI”). Our policy is available on our website at USD245ks.org. Please feel free to download and print it at your convenience.
*
Please Select
I have read and understand where to find to find ESI
Other
In order to receive accurate at-risk funding, we are required to gather the following information. Please fill out the required information and select any of the at-risk criteria that apply to your household. This information is confidential and will only be used for recording accurate numbers for the purposes of our district funding.
Please select all that apply:
*
My household qualifies for free meals under the National School Lunch Program.
Custodial parent is unmarried on the first day of school.
At least one parent was a teenager when the child was born.
At least one parent is lacking a high school diploma or GED on the first day of school.
The primary language in the household is not English, and the student has limited English proficiency.
Student has lower than expected developmental progress in at least one of the following areas: cognitive development, physical development, communication/literacy, social-emotional behavior and adaptive behavior/self-help skills.
None of the above are applicable.
I understand that the submission of this form serves as my “electronic” signature and replaces a hand written signature in all questions answered above:
*
Please Select
Yes
No
Please list your First/Last name below along with your last 4 SS #digits. This indicates that you are the legal guardian of the above mentioned student and are the person filling out this form.
*
ex: John Doe - 5515
Submit
Should be Empty: