Central Cass Public School

Kindergarten Screening 
for the 
2020-21 School Year

Student Information

Gender *
Are you for sure sending your child to kindergarten for the 2020-2021 school year? *
Race/Ethnicity *
Special Services (Check any that apply)
Does your Child speak any language(s) other than English? *
Do you give consent to have your child screened for hearing or speech at school if needed? *
Does your child have any health concerns we should be aware of? *

Parent/Guardian #1 Information:

Relationship to Child *
Check any that apply

Parent/Guardian #2 Information:

Relationship to Child
Check any that apply

Additional Contact:

Emergency Contact #1:

Emergency Contact #2:


Please list Siblings & Ages
Will ride Rural Bus *
Federal law mandates that we ask the following question:
What is your CHILD'S family living situation? *