Kindergarten Enrollment Form

Kindergarten Enrollment Form

Enrollment Details

Enrollment Type:   Program:   Requested Start Date:

Student Information

Date of Birth:   Sex:   Student ID (if known):

Home Phone:   Primary Language Spoken at Home:

Parent / Legal Guardian Information

Relationship to Student:   Phone:   Email:

Relationship:   Phone:

Emergency Contacts & Medical Information

Emergency Contact 1 (if guardian unavailable): Name   Phone:

Emergency Contact 2: Name   Phone:

Will the child require medication at school?   If yes, specify medication, dose and schedule:

Immunization and Records

I certify that the following documents are provided as required for enrollment (check all that apply):

Birth Certificate     Immunization Record     Proof of Residency

Prior School Records (if applicable)

Special Services and Needs

Does the student have an active Individualized Education Plan (IEP) or 504 Plan? IEP 504 Plan

Transportation

Primary mode of arrival and dismissal: Bus Parent Pickup Walker Other

Permissions and Acknowledgments

Media Release: I authorize the school to use photographs, audio, and/or video of my child for educational, promotional, or informational purposes. Yes No

Field Trip Authorization: I authorize my child to participate in supervised local field trips during the school year. I acknowledge that I will be notified of scheduled trips and given opportunity to withhold permission for any trip.

Emergency Medical Treatment Authorization: If I cannot be reached in an emergency, I authorize school personnel to obtain emergency medical treatment for my child and to release medical information as necessary for treatment. I understand that attempts to contact me will continue and that I am responsible for related medical expenses.

Attendance and Conduct Acknowledgment: I have read and understand the school attendance policy and code of conduct for students. I agree to cooperate with school staff to promote the safety, wellbeing, and education of my child.

Certification and Signature

I certify under penalty of perjury that the information provided on this form is true and complete to the best of my knowledge. I understand that falsification of residency or identity documents may result in withdrawal of enrollment. I authorize the school to verify any information provided and to request supporting documentation. I further acknowledge that submission of this form does not guarantee placement; enrollment is contingent upon completion of required records and school capacity.

Parent/Guardian Printed Name:

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