KILLINGLY PUBLIC SCHOOLS

KPS PreSchool c KMS c KCS c KIS c KHS c Current Grade: _____ SASID: ______

STUDENT INFORMATION

Student Name: ______

Last First Middle

Birth Date (DOB): ______Male Female State/Country of Student’s Birth: ______

Home Address: ______

Street (No PO Box) City ST Zip

1. Is the current address for this student a temporary living arrangement? Yes No

2. Is this temporary living arrangement due to loss of housing or economic hardship? Yes No

Mailing Address: ______

Street or PO Box City ST Zip

Primary Phone: ______Siblings Full Name/YOB: ______

Student Cell Phone: ______Student Email: ______

Student Resides with (Check all that apply) ☐ Both Parents ☐ Mother ☐ Father ☐ Stepmother ☐ Stepfather ☐ Foster Parent ☐ Other (please specify) ______

Do both parents/guardians listed below have the authority in all school and medical matters? Yes ___ No ___

Is there anything about your family arrangement that we should be aware of (split/joint/sole custody, guardianship, grandparent, etc) Please explain: ______

MOTHER INFORMATION FATHER INFORMATION

Mother Name: ______Father Name: ______

(Last, First) (Last, First)

Mother Home Phone: ______Father Home Phone: ______

Mother Cell Phone: ______Father Cell Phone: ______

Mother Employer: ______Father Employer______

Employer Address:______Employer Address:______

Employer Phone: ______Employer Phone: ______

Mother Email Address: ______Father Email Address: ______

GUARDIANSHIP INFORMATION

Name: ______Relationship: ______

(Last, First)

Mailing Address: ______

Street City ST Zip

Home Phone: ______Cell Phone: ______E-Mail: ______

Employer: ______Work Phone: ______

AFTER SCHOOL/DAY CARE INFORMATION

After School Contact: ______Relationship: ______

(Last, First)

Home phone: ______Cell Phone: ______

2ND MAILING INFORMATION

(If a 2nd mailing is needed, please fill in the following information)

2ND Mailing Name: ______

2ND Mailing Address: ______

Street City ST Zip

In order for us to determine your eligibility, please provide us with the following information:

Estimated Yearly
Gross Income / $ / Number of Family
Members

ALTERNATE EMERGENCY CONTACT INFORMATION

(If parents/guardians cannot be reached for transportation or illness)

Emergency #1 Name ______Relationship: ______

#1 Daytime Phone: ______#1 Cell Phone: ______#1 Work Phone: ______

Emergency #2 Name ______Relationship: ______

#2 Daytime Phone: ______#2 Cell Phone: ______#2 Work Phone: ______

Emergency #3 Name ______Relationship: ______

#3 Daytime Phone: ______#3 Cell Phone: ______#3 Work Phone: ______

AUTHORIZATIONS

The Killingly Board of Education requires parents to acknowledge the use of the internet as well as allowing their child to be photographed. Do you give permission for your child to:

Be interviewed by military personnel? YES NO

Use the internet? YES NO

Have their photograph taken? YES NO

LANGUAGE

RACIAL/ETHNIC BACKGROUND

Please circle YES or NO to EACH of the following questions:

Question 1 Is your child Hispanic or Latino? YES NO

Question 2 Is your child American Indian / Alaska Native? YES NO

Question 3 Is your child Asian? YES NO

Question 4 Is your child Black / African American? YES NO

Question 5 Is your child Native Hawaiian / Pacific Islander? YES NO

Question 6 Is your child White? YES NO

HEALTH INFORMATION & AUTHORIZATION

Primary Care Physician Name: ______ Physician Phone Number: ______

Dentist Name: ______Dentist Phone: ______

Significant Medical History: (Medical Diagnosis, Allergies, Medications, Restrictions, etc.) ______

______

My child has Health Insurance: YES NO Name of Insurance Company: ______

I, the undersigned, do hereby authorize officials of the Killingly School District to contact directly the persons named on this registration and do authorize the named physicians to render such treatments as may be deemed necessary in an emergency, of this child. I will not hold the school district financially responsible for the emergency care or transportation of this child. ______(parent/guardian initials)

KINDERGARTEN REGISTRATION ONLY

PRIOR SCHOOL ATTENDED

______

Prior School Name City/State Phone Date(s) Last Attended

PHOTOGRAPHY/VIDEO RELEASE

The KILLINGLY PUBLIC SCHOOLS are hereby authorized to obtain and/or release any photograph(s) video(s) or other form(s) of photography or video technology of my child for school related or informational purposes. All photography and video taping will be obtained during officially sanctioned school activities on or off school property. ______(parent/guardian initials)

COMMUNITY FIELD TRIPS

I give my child,______, permission to attend and participate in any activities conducted in the general neighborhood of the Goodyear Early Childhood Center, including but not limited to, trips to the local post office, nature walks, visits to other building spaces, the garden area in the backyard, etc.. I understand that these “mini” excursions will be supervised, as are all the extended field trips.______(Parent/Guardian Initials)

STUDENT/PARENT HANDBOOK INFORMATION

Please initial the box to indicate you will review the Student/Parent Handbook online at www.killinglyschools.org Select the appropriate school.

If you do not have internet access in your home, please check the box to the left to receive a copy of the Student/Parent Handbook.

I confirm that the information contained on this registration is current and accurate. I understand and accept the policies and procedures set forth in the handbook.

Parent/Guardian Signature Parent/Guardian Name (please print) Date

KILLINGLY PUBLIC SCHOOLS PRESCHOOL

______

HEALTH/BEHAVIOR OBSERVATIONS

The following list includes descriptions which may apply to any preschool child at one time or another. In rating each description for your child, please consider how the description fits him/her in comparison to other preschoolers of the same age and sex.

Place a check mark (ü) in the appropriate column for each description

DESCRIPTION / DEFINITELY
TRUE / SOMEWHAT
TRUE / NOT
TRUE / CANNOT
SAY
1.  Is often tired or tires easily
2.  Complains often of feeling ill
3.  Has frequent accident/injuries
4.  Speech unclear/stutters/stammers
5.  Seems to get ill often
6.  Sucks thumb/chews on clothing/bites nails
7.  Has accidents with bowel movements/soils underwear
8.  Frequently doesn’t hear what you say
9.  Body is in constant motion
10.  Is easily distracted
11.  Can’t keep hands to him/herself
12.  “Tune Out” intermittently
13.  Seems to have too much energy
14.  Stares for long periods
15.  Starts things but doesn’t finish them
16.  Seems to have too little energy
17.  Cries easily
18.  Is very quiet
19.  Is solitary
20.  Frequently appears sad or worried
21.  Has talked about hurting self or disappearing
22.  Has difficulty interacting with others
23.  Gets angry easily
24.  Clings excessively to adults
25.  Often starts fights with other children
26.  Has trouble separating from home to attend day care/school
27.  Gets picked on by other children
28.  Usually seems happy
29.  Is developing friendships
30.  Has good sense of self in space
31.  Easily becomes involved in many activities
32.  Enjoys new experiences
33.  Is able to share/cooperate with others
34.  Stands up for self when necessary
35.  Accepts rules easily

COMMENTS:______

______

Parent Signature Date