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