KILLINGLY PUBLIC SCHOOLS

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

STUDENT INFORMATION

Student Name: ______

LastFirstMiddle

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

Home Address: ______

Street (No PO Box)City STZip

1. Is the current address for this student a temporary living arrangement?YesNo

2. Is this temporary living arrangement due to loss of housing or economic hardship? YesNo

Mailing Address: ______

Street or PO BoxCitySTZip

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 INFORMATIONFATHER 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: ______

PARENT/GUARDIAN INFORMATIONPARENT/GUARDIAN INFORMATION

Guardian Name: ______Guardian Name: ______

(Last, First)(Last, First)

Guardian Home Phone: ______Guardian Home Phone: ______

Guardian Cell Phone: ______Guardian Cell Phone: ______

Guardian Employer: ______Guardian Employer______

Employer Address:______Employer Address:______

Employer Phone: ______Employer Phone: ______

Guardian Email Address: ______Guardian Email Address: ______

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: ______

StreetCitySTZip

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?YESNO

Use the internet?YESNO

Have their photograph taken?YES NO

RACIAL/ETHNIC BACKGROUND

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

Question 1Is your child Hispanic or Latino?YESNO

Question 2Is your child American Indian / Alaska Native?YESNO

Question 3Is your child Asian?YESNO

Question 4Is your child Black / African American?YESNO

Question 5Is your child Native Hawaiian / Pacific Islander?YESNO

Question 6Is your child White?YESNO

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 NameCity/StatePhoneDate(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 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 and I have thoroughly reviewed the program’s discipline policy.

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

Killingly Public Schools Home Language Survey

Welcome to our school!

We have a few questions about languages spoken at home. We are required by the US Department of Education to ask for this information because it will help us know how we can best support your child. The language information also helps us know how we can best communicate with you. Please share with us about the language(s) spoken by your family and in your home.

______Student Information

Student first name: Student last name:

Country of birth:

Date of birth:

Date first enrolled in any US school:

______

1)What is the primary language used in the home, regardless of the language spoken by the student?

2)What is the language most often spoken by the student?

3)What is the language the student first acquired?

What language do you prefer for written communication from the school?

1)Will you require interpretation/translation at Parent-Teacher meetings?

______

Parent/guardian name (please print)

______

Parent/guardian signature Date

Thank you for answering the questions. We look forward to working with your child.

Killingly Family Resource Center

Family Needs Assessment

Participation in this survey is optional, however, responses may assist families with resources and enrollment.

1. What is your marital status? ____Single ____Married ____Separated

____Living Together ____Widowed ____Divorced

2. How many people live in your household? _____Adults _____Children

Are you currently expecting? ____Yes ____No

3. Do you: ____Own ____Rent ____Reside with family or friends

Other:______

4. How many adults in your household are currently employed? ______

What is the current annual household income?

Do you receive SSI? ____Yes ____No

Do you receive child support? ____Yes ____No

5. Do you have access to reliable transportation? ____Yes ____No

If no, are you able to get yourself and your children back and forth to appointments, etc.? ____Yes ____No ____Sometimes Difficult

Will your child need transportation to get to/from school? ____Yes ____No

6. Would a member of your household be interested in completing a G.E.D. or

participating in other adult education? ____Yes ____No

7. Would a member of your household be interested in employment resources?

____Yes ____No

8. What services do you currently utilize? 9. What would you be interested in?

____Food Pantry ____TANF ____Food Pantry ____TANF

____WIC ____Husky Health ____WIC ____Husky Health

____Heating Assistance ____Heating Assistance

____Diaper Bank ____SNAP ____Diaper Bank ____SNAP

____DCF Support ____DCF Support

____Clothing Assistance ____Clothing Assistance

____Counseling Services ____Counseling Services

____Access Agency ____Access Agency

____Sect. 8/Supportive Housing ____Sect. 8/Supportive Housing

____Pediatric Dental Screenings/Care ____Dental Screenings/Care

10. In which areas do children and families in your community face the greatest

challenges?

11. What prevents you and your family from accessing available services you may

need?

12. Would you be interested in information about becoming a foster or adoptive parent?

_____Yes _____No

13. Were you referred by a community agency? ______Yes ______No

If yes, agency name______.

14. Is there anything else you would like to tell us about your child or family?

* In the event that my 3-4 year old child is on the wait list, I give permission for Killingly Public Schools Preschool to share my application and attachments with EASTCONN Head Start. ______Yes ______No

Parent/Guardian signature______Date______