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80A–18th Street Northeast, Weyburn, SK S4H 2W4

Telephone: (306) 848-0080 Fax: (306) 848-4747

www.cornerstonesd.ca

South East Cornerstone Public School Division No. 209

Application for Admission to Prekindergarten Program

Date of Application School
YY / MM / DD

Student Information

Last Name
Given Names / Name Used
Birth Date
DD / MM / YY / Male Female / Home Phone Unlisted:
Mailing Address
City / Postal Code
School child will attend in Kindergarten

Parent/Guardian Information

Father's Last Name First Name
Address (if different from student's) / Home Phone / Cell Phone
Daytime Commitment (Name of Workplace) / Work Phone / Email Address
Mother's Last Name First Name
Address (if different from student's) / Home Phone / Cell Phone
Daytime Commitment (Name of Workplace) / Work Phone / Email Address

Child Care Provider – before school and/or after school

Last Name / First Name
Address / Home Phone / Cell Phone

Emergency Contact Information

Last Name / First Name
Address / Home Phone / Cell Phone
Relationship to Child

Background Information

Is there a legal custody arrangement? (Documentation requested upon admittance) ______yes ______no
Mother has full custody_____ Father has full custody______
Joint/Shared custody ______Guardian has full custody_____
Child lives with both mother and father ______Other ______
First Nations Métis English as an additional language?
Country of birth______Country of Citizenship______
Highest level of education obtained: By mother ______By father ______
Sibling Information (names, ages school attending, relationship – step,blended, living together, etc.) ______
______
______
Early Learning Behaviours and Experiences
Is your child toilet trained? _____ yes ______no
Does your child separate easily from you? ____yes ____no
Is your child shy? ____yes ____no Withdrawn? ____yes ____no Aggressive? ____Yes ____no
Has your child been receiving speech therapy? ____yes ____no
Please list all languages spoken in the home.______
Do others have difficulty understanding your child’s speech? ____yes ____no
Does your child have difficulty retelling the events of stories or TV shows? ____yes ____no
Please describe how your child plays (with others, by him/herself)______
______
Please describe how your child shows his/her feelings. ______
______
Please add any additional information that would help us know your child better.______
______
Is there any additional information about your family that you feel your child’s teacher/principal should know (i.e. medical, family supports, etc.)?______
______
Are you being supported by any of the following services or programs available in our community?
Licensed child care Play school/Preschool
Early Learning and Care ASD
Social Services Early Childhood Psychologist
Aboriginal Head Start Other Please specify______
How did you hear about the prekindergarten program?______
Health History
Saskatchewan Health #______Doctor’s name and phone______
Child’s birth weight ______Please list any problems during pregnancy with this child, at birth or immediately after birth______
______
If you have any concerns about the child’s development, such as age of sitting, walking or talking, please provide appropriate details. ______
Has your child had frequent ear aches or infections? ____yes ____no Tubes in ears? ____yes ____no
Does your child have any allergies? ____yes ____no If yes, please list and include whether or not the child uses an inhaler, etc. ______
______
Has your child received a vision test by an optometrist? ____yes ____no Date______
Does your child wear glasses? ____yes ____no If yes, all times______Classroom only_____
Does your child wear a hearing aid? ____yes ____no

Consent:

I hereby consent to the release of information to the Prekindergarten Selection Committee by any identified agency contained in this application that may pertain to my child’s eligibility for enrolment in the Prekindergarten program at South East Cornerstone Public School Division.

The information contained in this application will be held in confidence by the Prekindergarten Selection Committee.
Parent's signature / Date

Please submit applications to:

Arcola School - 302 Souris Ave. ARCOLA SK S0C 0G0Telephone: 455-2340 Attention: Ron Wardrope

Carnduff Education Complex – 506 Anderson Ave. CARNDUFF SK S0C 0SO 482-3491 Attention: Ryan Nichols

Carlyle Elementary School - Box 789 CARLYLE SK S0C 0R Telephone: 453-2393 Attention: Tyler Fehrenbach

Haig School - 1113 Coteau Ave E WEYBURN SK S4H 0H5 Telephone: 842-2812 Attention: Arlene Dobson

MacLeod Elementary School - Box 900 MOOSOMIN SK S0G 3N0 Telephone: 435-3878 Attention: Carolin St. Onge

Oxbow Prairie Horizons School - Box 660, 860 Tupper St. Oxbow, SK S0C 2B0 (306)-483-2383 Attention: Jason Petlak

Westview School- 1607 2nd Street Estevan, SK S4A 0M9 (306)-634-2241 Attention: Cheri Haberstock