EVESHAM TOWNSHIP SCHOOLS
Registration Questionnaire
Name of Child Grade Male Female
(Last) (First) (Full Middle) (Generation)
Nickname Date of Birth
Address of Child City/State of Birth
Home Telephone # Country of Birth
Mother’s Name Mother’s Home Phone
(Last) (First)
Address if different from Child Mother’s Work Phone
Mother’s e-mail address Mother’s Cell Phone
Mother’s Occupation Mother’s Place of Employment
Father’s Name Father’s Home Phone
(Last) (First)
Address if different from Child Father’s Work Phone
Father’s e-mail address Father’s Cell Phone
Father’s Occupation Father’s Place of Employment
Guardian’s Name Guardian’s Home Phone
(If Other Than Parent) (Last) (First)
Address if different from Child Guardian’s Work Phone
Guardian’s e-mail address Guardian’s Cell Phone
Guardian’s Occupation Guardian’s Place of Employment
Parent(s): Together Separated Divorced Remarried Single
Deceased: Father Mother
Child resides with: Father Mother Stepfather Stepmother
Other: (explain relationship)
Other Children in Family (If additional space needed, please use other side)
(Oldest to Youngest)NAME / Date Of Birth
Month / Day / Year / Place of Birth / Name of School/Grade
Attended
Is another language besides English spoken in your home? Yes No If yes, what language?
Has your child ever received English as a Second Language services (ESL)? Yes No If yes, what grade(s)?
Has your child ever repeated a grade? Yes No
Is your child currently receiving any specialized school program/related services or does your child have an IEP or 504 Plan?
Name of Previous School / Complete Address(Town, County, State, Country) / Phone Number / Dates Attended
Type of School: Public Private Home School
What development do you live in?
Do you: Own your dwelling? Rent your dwelling?
Parent’s Name:
(Please print)
Parent’s Signature: Date:
(Please sign in ink)
It is understood that if residence in Evesham Township is not established within 60 school days of the date the child begins attending school, tuition will be charged.
For Office Use Only: School: hlb des dms fve rbj mes mms rlr vz
Teacher First Day on Roll Transp Start Date:
Proof of Residency (list)
Birth Certificate
Proof of Immunization
Name of Child Grade
(Last) (First) (Full Middle) (Generation e.g. Jr., Sr.)
Race/Ethnicity Background Information for NJ SMART
The state department has a mandate in relation to a statewide student data based system entitled NJ SMART. Each district is required to keep specific information on every student.
In order to help us enter the accurate fields of data, please complete the following information regarding your child:
1. Please check all that apply:
White (A person having origins of the original peoples of Europe, the Middle East or North Africa)
Black or African American (A person having origins in any of the black racial groups of Africa)
Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam)
American Indian or Alaska Native (A person having origins in any of the original people of North and South America (including Central America) and who maintains a tribal affiliation or community attachment)
Native Hawaiian or Other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands)
2. Is the student Hispanic or Latino? (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race) Yes No
*NOTE: All descriptors are taken directly from the NJ SMART Student Data Handbook V1.3
Parent’s Name:
(Please print)
Parent’s Signature: Date:
(Please sign in ink)
EVESHAM TOWNSHIP PUBLIC SCHOOLS
MARLTON, NJ 08053
REGISTRATION HEALTH HISTORY and QUESTIONNAIRE
(To be completed by parent)
Name of Student Date of Birth
Check diseases child has had with the date of illness:
Chicken Pox / German Measles / Rheumatic FeverMeasles / Scarlet Fever / Diphtheria
Whooping cough / Mumps / Poliomyelitis
At what age has child had any of the following operations:
Tonsillectomy / HerniaAppendectomy / Other
Ear Tubes Inserted
Does the child have any medical history of the following:
Epilepsy or Neurological Disorders / Kidney DisordersDiabetes / Heart Disease
Orthopedic Deformities / Allergy to Food or Insect Sting
Asthma / Snoring or Sleep Problems
1. Does the child have any difficulty with speech or word pronunciation? No Yes
2. Does the child have any difficulty with vision or wear glasses? No Yes
3. Does the child have any difficulty with hearing or use hearing aids? No Yes
Parents’ Remarks
If your child has an allergy or a reaction to medication or any other chronic illness, or medical condition, please describe below (use other side of paper if necessary):
Parent’s Name:
(Please print)
Parent’s Signature: Date:
(Please sign in ink)
EVESHAM TOWNSHIP SCHOOL DISTRICT
MARLTON, N.J. 08053
PHYSICAL EXAMINATION
(To be completed by physician)
Name of Child Date of Birth
IMMUNIZATIONS
DPT (diptheria, pertussis POLIO MMR #1 HIB
tetanus) (specify IPV or OPV) MMR #2
1. 1.
2. 2.
3. booster Varicella #1
booster booster Varicella #2
Tdap or Td (circle one) PCV (Prevnar)
Gardasil (HPV) #1 #2 #3
Hepatitis B #1 #2 #3 Hepatitis A #1 #2
Tuberculin test type results date
INFLUENZA (most recent) MENINGIOCOCCAL
MEDICAL HISTORY
Allergies Diabetes
Asthma Kidney disorders
Cardiac disorders Neuromuscular disorders
Convulsive disorders
Congenital defects Surgeries or injuries:
PHYSICAL EXAMINATION Height Weight BP
Ears Heart Posture
Eyes Lungs Nervous system
Nose Abdomen Nutrition
Throat Hernia
Teeth Genito/Urinary Speech
Glands Skin
Vision Hearing
General appearance
Does this child regularly take medication?
Comments or Recommendations
Doctor’s signature Date of exam Office stamp
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EVESHAM TOWNSHIP SCHOOL DISTRICT
MARLTON, N.J. 08053
DENTAL
Dear Parent or Guardian:
If your child has been to the family dentist or pediatric dentist, please have them sign and return as soon as possible.
School Nurse
Date
School
Grade
Student
Has been examined and is now receiving treatment
Treatment has been completed
No treatment necessary
Dentist’s Name:
(Please Print)
Dentist’s Signature: Date:
(Please sign in ink)
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EVESHAM TOWNSHIP SCHOOL DISTRICT
MARLTON, N.J. 08053
KINDERGARTEN PARENT QUESTIONNAIRE
NAME OF CHILD: DATE:
NICK NAME (optional):
Please complete the following questions, as this information may be of great value to us. Thank you for your cooperation.
I. GROSS MOTOR SKILLS (Please check)
Can your child:
Climb?
Hop?
Skip?
Jump?
II. FINE MOTOR SKILLS (Please check)
Can your child:
Use scissors?
Use crayons?
Use paints?
Tie shoes?
Zip and button clothes?
Is your child left handed or right handed? (Circle) R L
III. ACTIVITY LEVEL (Please check yes or no)
Is your child: YES NO
A. Always active?
B. Restless?
C. Unpredictable?
D. Generally calm?
E. Slow in responding?
F. Generally consistent in behavior?
G. Generally inconsistent in behavior?
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IV. READINESS SKILLS (Please check and add any information)
Does your child:
Recognize the letters of the alphabet? capital small
Read?
Like being read to?
Finish what he/she starts?
Articulate clearly?
COMMENTS:
V. PERSONALITY TRAITS (Please check words which usually apply to your child’s HOME behavior. Add comments if you wish.)
Shy Accepts criticism
Quiet Easily influenced by others
Energetic Outgoing
Moody Controlling
Stubborn Dawdles
Apprehensive Argumentative
Waits for help Obeys slowly
Proceeds independently Puts things away
Feelings get hurt easily Self confident
Hesitant about new situation Sensitive
Complains easily Talkative
Prefers company of adults Demanding
Exhibits self control Cries easily
Has temper tantrums Has fears – Explain:
3
VI. ATTITUDE TOWARD SCHOOL (Please check)
Does your child:
Seem excited about kindergarten?
Seem ready for school?
Want to stay home, but will come without getting upset?
Seem worried about starting?
What do you think we should know about your child that would make his/her progress in kindergarten most effective?
Other comments:
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