• Early Childhood/Verona Area First Five Years/Pre-K Request for Assistance Form

  • Birthday*
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  • Gender*
  • Relationship to Child*

  • Child, Family, and Child Care Information

  • Is the child Hispanic or Latino?*
  • What is the child's primary race? (select all that apply)*
  • Would you like to request translation and/or interpretation services?
  • On weekdays, the child is at (select all the apply)

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  • Do parent(s)/guardian(s) give permission to Verona Area School District staff to observe the child in the weekday setting listed and to share information with staff at the weekday setting?*
  • Describe parent teacher communications that have been held to discuss the area of concern*

  • Parent/Guardian Information

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  • Secondary Parent/Guardian Information

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  • Does secondary parent/guardian reside at the same address as the child and primary guardian
  • Does the child have any school age siblings attending Verona Area School District or siblings not yet attending Verona Area School District?*

  • Siblings

  • Information about Child and Concern(s)

  • This request is for concerns in the following area(s) of (check all that apply):*

  • Temperment Traits

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  • Have you looked at these Behavior/Social resources?
  • Has the child had an evaluation in any area of development? (Check all that apply)

  • For each area of development selected above, please fax reports to 844.787.4713, Attn: Rachelle McCullough.

  • Electronic Signature

    The electronic signature below and its related field(s) are treated by Verona Area School District like a handwritten signature on a paper form (Board Policy 773, Use of Electronic Signatures)

  • I agree that the information provided herein is complete and accurate. I understand that this information is being used by the Verona Area School District for the purposes of enrolling/potentially evaluating my child. I understand that incomplete or inaccurate information may delay, prevent or invalidate my child's enrollment in school. I agree to promptly inform Verona Area School District of any changes to this information, including any changes in residence of my child.

  • Date*
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  • Reload
  • Should be Empty: