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Central Cass Public School
Kindergarten Screening
for the
2020-21
School Year
Student Information
Student's Legal Name, First
*
Middle
*
Last
*
Birthdate (MM/DD/YYYY)
*
+
Name you want your child to go by at school
*
Gender
*
Male
Female
Are you for sure sending your child to kindergarten for the 2020-2021 school year?
*
Yes
No
Undecided
Race/Ethnicity
*
African American
Asian
Caucasian/White
Hispanic/Latino
Native American or Alaska Native
Other
Other
Special Services (Check any that apply)
Current IEP
504 Plan
Title 1
EMH
LD
Speech
Other
Other
Does your Child speak any language(s) other than English?
*
Yes
No
If "Yes" please list:
If "Yes" please list:
Do you give consent to have your child screened for hearing or speech at school if needed?
*
Yes
No
Does your child have any health concerns we should be aware of?
*
Yes
No
If "Yes" please list:
If "Yes" please list:
Student's Primary Address
*
City
*
State
*
Zip Code
*
Parent/Guardian #1 Information:
Parent/Guardian #1 Name:
*
Relationship to Child
*
Father
Mother
Other (Please List)
Other (Please List)
Check any that apply
Student resides with parent/guardian
Student resides in your Foster Home
Cell Phone Number
Home Phone Number
Email Address
Address (If different from child):
City
State
Zip Code
Employer
Work Phone Number
Parent/Guardian #2 Information:
Parent/Guardian #2 Name
Relationship to Child
Father
Mother
Other (Please List)
Other (Please List)
Check any that apply
Student resides with parent/guardian
Student resides in your Foster Home
Cell Phone Number
Home Phone Number
Email Address
Address (If different from child)
City
State
Zip Code
Employer
Work Phone Number
Additional Contact:
Name
Relationship
Home Phone Number
Cell Phone Number
Work Phone Number
Email Address
Address
City
State
Zip Code
Emergency Contact #1:
Name
Relationship
Phone Number #1
Phone Number #2
Emergency Contact #2:
Name
Relationship
Phone Number #1
Phone Number #2
Other:
Daycare Provider (If applicable)
Other adults allowed to pick up your child who are not listed above:
Please list Siblings & Ages
+
-
Will ride Rural Bus
*
Yes
No
Federal law mandates that we ask the following question:
What is your CHILD'S family living situation?
*
Own a mobile home or house
Rent an apartment, mobile home, house or other living space with your name on a lease for that location
Share housing with family, friends or others due to a economic hardship, loss of housing or similar reason and your name is NOT on a lease for that location
In a hotel/motel
In a camper/5th Wheel, care or public place (parking lot, construction site, trucks yard, private yard, park, abandoned building)
Move from place to place
At an emergency transitional shelter
Live alone without an adult
Lives with an adult that is not his/her parent or legal gaurdian