WOODRUFF PRIMARY SCHOOL
PRESCHOOL THREEKINDERGARTEN INFORMATION SHEET
STUDENT INFORMATION
FULL NAME: ______GRADE: 3K_____ 5K _____
NAME CALLED: ______SEX: Male______Female ______
SOC. SEC. #:______BIRTH CERT. # ______BIRTH DATE: ______
Mo/Day/Yr
ARE YOU HISPANIC OR LATINO? ______YES______NO
WHAT IS YOUR RACE? _____ African American_____ American Indian or Alaska Native ____ Asian
_____ Hawaiian Or Pacific Islander_____ White
ADDRESS: ______
P.O. BOX(If Applicable): ______(City)______(State)____ Zip: ______
MOTHER/STEPMOTHER/GUARDIAN (WITH WHOM CHILD LIVES):
NAME: ______AGE: _____ HOME PHONE:______
PLACE OF EMPLOYMENT: ______WORK PHONE: ______
EDUCATIONAL LEVEL OF MOTHER/STEPMOTHER/GUARDIAN: (check one)
___ Less Than 9th Grade ___ Less Than High School ___ GED
___ High School Graduate ___ Technical School Graduate ___ College Graduate
FATHER/STEPFATHER/GUARDIAN (WITH WHOM CHILD LIVES):
NAME: ______AGE: ____HOME PHONE:______
PLACE OF EMPLOYMENT: ______WORK PHONE: ______
EDUCATIONAL LEVEL OF FATHER/STEPFATHER/GUARDIAN: (check one)
___ Less Than 9th Grade ___ Less Than High School ___ GED
___ High School Graduate ___ Technical School Graduate ___ College Graduate
CHILD’S FAMILY INCOME IN THE PAST TWELVE (12) MONTHS:
______$0 - $10,000 ______$10,001 to $20,000 _____$20,001 to $30,000 _____$30,001 to $40,000
______$40,001 to $50,000 ______$50,001 to $60,000 ______over $60,000
CURRENT CHILD CARE PROVIDER:
______CENTER-BASED CHILD CARE (A private childcare center.) ______HEAD START
NAME OF CHILD CARE CENTER: ______
______HOME WITH FAMILY MEMBER ______HOME WITH NON-FAMILY MEMBER
______FAMILY CHILD CARE (HOMEBASED) (Someone keeps a small group of children in the home)
STUDENT HEALTH:
Does the child have a health problem that will impact regular attendance in school?
YES _____NO ______If yes, please describe: ______
OTHER SPECIAL HEALTH CONDITIONS (Allergies to foods, reactions to bee stings, etc.)
YES ____ NO _____ If yes, please describe: ______
MEDICAL CARE PROVIDER: (List the source the family generally uses for their medical care)
FAMILY PHYSICIAN: ______DENTIST: ______
EMERGENCY ROOM: ______CLINIC: ______OTHER: ______
TOILETING NEEDS:
Child is…
____ Completely toilet trained (rarely has accidents)
____ Somewhat toilet trained (currently has accidents, but should be completely toilet trained by start of school)
____ Not toilet trained
IF PARENTS CANNOT BE REACHED IN CASE OF EMERGENCY OR ILLNESS, PLEASE NOTIFY:
NAME RELATIONSHIP TELEPHONE #
1. ______
2. ______ ______
3. ______
LIST ALL OTHER CHILDREN IN FAMILY:SEX AGE GRADE SCHOOL ATTENDING
1. ______
2. ______
3. ______
METHOD OF TRANSPORTATION:(How child will be transported)
______BUS______CAR______NURSERY VAN
(NOT AN OPTION FOR 3K)
GIVE DIRECTIONS TO HOME: This information is only necessary if you live outside the Woodruff City limits.
______
My child and I are legal residents of Spartanburg District Four.
PROOF OF RESIDENCY: Tax Receipt _____ Lease/Rental Agreement In Parent/Guardian’s Home ______
I attest that I am the parent or legal guardian and all information provided is true and accurate.
______
Parent/Guardian SignatureDate
Preschool Plus Info Sheet – revised –03/09/2015 - CD