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Kindergarten Registration Form
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Kindergarten Registration Form

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  • 1. 1 FAYETTE COUNTY PUBLIC SCHOOLS REGISTRATION APPLICATION FORM For School Use Only Enrollment Date: Enrollment Code: Student Number: TIME/DATE STAMP Room: Teacher: Grid # Geo Code: Neighborhood # Transportation Code: Bus Stop: Last Name AM Bus: Date Cum Requested: STUDENT INFORMATION First Name Middle Physical Address Student’s Birth Date Score: State Sex F Last School or Preschool Attended Grade City Student’s Social Security # (Optional) Asian Native Hawaiian or Other Pacific Islander Zip Is the student Hispanic/Latino? Yes No M American Indian or Alaska Native Race – Required (Check one or more): PM Bus: Nickname Apt Phone HR: White Grade Completed Black or African American Address Telephone Other Information (Please check if applicable): IEP 504 Plan Primary Language: Foster Home English PE Waiver Migrant Homeless Refugee/Immigrant Other: _________________________________________________ HOUSEHOLD AND PARENT/GUARDIAN INFORMATION PARENT/GUARDIAN #1 Last Name First Name Middle Name Sex F Relationship to Student: Home Phone Parent Guardian Stepparent Work Phone Other ______________________ Cell Phone Address (if different from student’s) Employer PARENT/GUARDIAN #2 Last Name Relationship to Student: Home Phone Occupation First Name , DOB: Apt Other Phone State Work Address Sex Middle Name F Foster Parent Stepparent Work Phone Other ______________________ Cell Phone Apt Work Address Zip Work Hours Guardian Occupation Guardian 1 Email Address City Parent Address (if different from student’s) Employer Foster Parent M Lives with student? Yes No City M Lives with student? Yes No Guardian 2 Email Address Other Phone State Zip Work Hours Please complete other side
  • 2. 2 SIBLINGS (please attach additional sheet if more room is needed) Name Birthdate Grade School Sex F M F M F M F Address (if different from student’s) M EMERGENCY INFORMATION OTHER THAN PARENT/GUARDIAN Last Name First Name Sex Middle Name F Mailing Address Home Phone City Work Phone State Zip Permission to pick up child from school? Yes No Relationship to Student Cell Phone M Persons who may not pick up your child: (If this is a parent, school must be supplied with court documentation) Name Relationship Court document supplied? Yes No Does your child have any severe or chronic medical conditions? If yes, please explain. Physician’s Name Phone Number Emergency Room Preference (If any) KINDERGARTEN KICKOFF INFORMATION Every school in Fayette County will host a Kickoff event for incoming kindergarten students prior to the start of school either in late July or August. Students will be given an appointment to come meet school staff and teachers and participate in a learning screener. Schools may sign families up during kindergarten registration for Kindergarten Kickoff or families will be contacted by the child’s assigned school at a later time with Kickoff information. ANY ADDITIONAL PARENT COMMENTS: FOR OFFICE USE ONLY ENROLLMENT PRIORITIES Address in primary attendance area? Student subject to prior board action? Older siblings at this school? Employee teaching at this school or campus? Yes Yes Yes Yes No No No No Yes Yes No No Number: Date: Date: Date: Date: No No No No DOCUMENTATION PROVIDED Address Documentation #1 Address Documentation #2 Birth Certificate Immunization Record Preventative Health Care Examination Eye Exam (Kindergarten Only) Dental Exam (Kindergarten Only) Social Security Card (not required) Court Documents (if applicable) Kindergarten Verification (if applicable) Records Release Request (if applicable) , DOB: Yes Yes Yes Yes Yes No No No No No Yes Yes Yes Yes
  • 3. 3 FAYETTE CO PUBLIC SCHOOLS HOUSEHOLD FORM STUDENT INFORMATION (PLEASE PRINT) Student Last Name Student First Name Student Middle Name Green 14-15 Date of Birth School Revised 12/07/13 Sex Female Male Grade Level Home Phone Number _____________________________________ Address Apt City PARENT/GUARDIAN #1 Guardian Last Name Guardian First Name State Geo Code (School Only) Zip Code Guardian Middle Name Is Guardian former FCPS student? Sex Yes Female Male Relationship to Student:  Parent  Stepparent Cell Phone  Guardian  Foster Parent  Other: _________________ Other Phone Work Phone Mailing Address (If student not living with guardian) Yes Guardian lives with student? Guardian Email Address Apt PARENT/GUARDIAN #2 Guardian Last Name Guardian First Name City State Guardian Middle Name Zip Code Is Guardian former Sex Yes Female Guardian lives with student?  Yes Should this Guardian receive mailing?  Yes Have rights to online student info?  Yes FCPS student? Relationship to Student:  Parent  Stepparent Cell Phone  Guardian  Foster Parent  Other: _________________ Other Phone Work Phone Mailing Address (If student not living with guardian) Apt City State Sex Female Cell Phone Secondary Contact Last Name Home Phone Third Contact Last Name Home Phone First Name Cell Phone First Name Cell Phone Male No No No Guardian Email Address EMERGENCY CONTACTS - OTHER THAN GUARDIAN Primary Contact Last Name First Name Middle Name Home Phone No Work Phone Middle Name Work Phone Middle Name Work Phone Zip Code Relationship to Student Male Home Address Sex Female Relationship to Student Male Home Address Sex  Female Relationship to Student Male Home Address *IF YOU HAVE ADDITIONAL STUDENTS ATTENDING FAYETTE CO. SCHOOLS WITH SAME GUARDIANS, ADDRESS AND EMERGENCY CONTACTS PLEASE COMPLETE OTHER SIDE. I certify the above information is correct and understand that I must contact the school with any changes. , DOB: __________________________________________________________________ Signature Date
  • 4. 4 O n l y co mp l ete i f you h ave ad d i ti on al ch i l d ren atten d i n g Fayette Cou n ty S ch o o l s w i th th e S AME GUA RD I ANS , ADDRE S S AND E ME RGE NC Y CO NT ACT S . Ad d i ti on al S tu d ent I n f ormati on STUDENT LEGAL NAME (Last Name, First Name Middle Name) (please print) DATE OF BIRTH SCHOOL SEX Female Male GRADE Ad d i ti on al S tu d en t I n f ormati on STUDENT LEGAL NAME (Last Name, First Name Middle Name) (please print) DATE OF BIRTH SCHOOL SEX Female Male GRADE Ad d i ti on al S tu d en t I n f ormati on STUDENT LEGAL NAME (Last Name, First Name Middle Name) (please print) DATE OF BIRTH SCHOOL SEX Female Male GRADE Ad d i ti on al S tu d en t I n f ormati on STUDENT LEGAL NAME (Last Name, First Name Middle Name) (please print) DATE OF BIRTH SCHOOL SEX Female Male GRADE Ad d i ti on al S tu d ent I n f ormati on STUDENT LEGAL NAME (Last Name, First Name Middle Name) (please print) DATE OF BIRTH SCHOOL SEX Female Male GRADE Ad d i ti on al S tu d en t I n f ormati on STUDENT LEGAL NAME (Last Name, First Name Middle Name) (please print) DATE OF BIRTH SCHOOL SEX Female Male GRADE Ad d i ti on al S tu d en t I n f ormati on STUDENT LEGAL NAME (Last Name, First Name Middle Name) (please print) DATE OF BIRTH SCHOOL SEX Female Male GRADE Guardian information on the other side MUST be completed. I certify the above information is correct and understand that I must contact the school with any changes. GREEN , DOB: __________________________________________________________________ Signature Date Revised 12/07/13
  • 5. “It’s About Kids” FAYETTE COUNTY PUBLIC SCHOOLS 1126 Russell Cave Road Lexington, KY 40505 (859) 381-4100 Student Health Information (Please complete one form per student) 2014-15 SCHOOL YEAR: ________________ SCHOOL: _______________________________________________________________ STUDENT INFORMATION (Please give student’s complete legal name) Last Name First Name Student’s Social Security # Middle Name Student’s Birth Date Race-Required (check one or more): Street Address Homeroom Teacher Sex F American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Apt City Is the student Hispanic/Latino? Yes No M Asian White Black or African American Zip PARENT/GUARDIAN AND EMERGENCY CONTACT INFORMATION Guardian 1 Name Relationship to Student Home Phone Work Phone Cell Phone Guardian 2 Name Relationship to Student Home Phone Work Phone Cell Phone Emergency Contact (Other than Guardian) Relationship to Student Home Phone Work Phone Cell Phone STUDENT’S Medical Insurance Does your student have a KY Medicaid or K-CHIP Card? Does your student have other medical insurance? Yes Yes No No Number ______________________________________ Name of Company__________________________________ STUDENT’S Medical History 1) Significant Medical History: ________________________________________________________________________ 2) Medication Allergies: _____________________________ Food Allergies: __________________________________ 3) Other Allergies: __________________________________________________________________________________ 4) Medications taken Daily: __________________________________________________________________________ 5) * Prescription Medication to be given at School: _______________________________________________________ Student’s Health Care Provider: __________________________________________ Phone: __________________________ *Must complete Medication Consent Forms prior to any prescription medications being brought to school to be administered. Forms are available at school. Does your student have any of the following life-threatening conditions that may require EMERGENCY treatment or medications to be given at school? DIABETES (Glucagon) ASTHMA (Rescue Inhaler) SEIZURES (Diastat) LIFE-THREATENING ALLERGY (Epi-Pen) OTHER: _____________________ CONSENT FOR HEALTH SERVICES All students will receive basic First Aid and emergency care. By signing this form, I consent to Health Services given to my student while at school. I authorize Fayette County Public Schools to release medical information about my student to his/her Primary Care Provider. EXPIRES ONE YEAR AFTER DATE SIGNED. X_______________________________ (Signature of Parent / Legal Guardian / Emancipated Student) ___ /___ /________ (Date signed) THIS SECTION FOR SCHOOL USE ONLY Care Plan(s) Sent Rev. 12/2013 Date: _____________ Date: _____________ Date: _______________ Date: ________________ Care Plan(s) Returned Date: _________________ Please Return Completed Form To School Date: __________________ 5
  • 6. 6 Fayette County Public Schools HOME LANGUAGE SURVEY Date 1/30/14 School ________________________________________ Grade ________________________ Child's Name ________________________________________________________________________________________________ First Name Middle Initial Last Name Parent or Guardian's Name _____________________________________________________________________________________ First Name Middle Initial Last Name Address ____________________________________________________________________________________________________ Street City State Zip Phone Number _______________________________________________________________________________________________ Home 1. Work _______________________ (Month/Date/Year) Was your child born in the United States? If yes, in which state? ❏ Yes ❏ No _____________________________________ If no, in what other country? _____________________________________ If no, date child entered the United States: 2. Child’s date of birth: _______________________ (Month/Date/Year) Has your child attended any school in the United States for any three years during their lifetime? Yes If yes, please provide school name(s), state, and dates attended: Name of School _______________________________________________ Name of School _______________________________________________ Name of School _______________________________________________ State ________ State ________ State ________ No Dates Attended _________________ Dates Attended _________________ Dates Attended _________________ 3. What is the language most frequently spoken at home? _____________________________________ 4. If available, in what language would you prefer to receive communication from the school? _____________________________________ 5. 6. Please check if your child is: A. ❏ Native American Indian B. ❏ Alaska Native C. D. ❏ ❏ Native Pacific Islander Native U.S. Virgin Islander ❏ Is your child’s first-learned or home language anything other than English? Yes ❏ No If you responded “Yes” to question number 6 above, please answer the following questions: 7. In what country did your child most recently reside? _____________________________________ 8. Which language did your child learn when he/she first began to talk? _____________________________________ 9. What language does your child most frequently speak at home? _____________________________________ 10. What language do you most frequently speak to your child? (Father) _____________________________________ (Mother) _____________________________________ 11. Please describe the language understood by your child. (Check only one) A. ❏ Understands only the home language and no English. B. ❏ Understands mostly the home language and some English. C. ❏ Understands the home language and English equally. D. ❏ Understands mostly English and some of the home language. E. ❏ Understands only English. ________________________________________________ Parent or Guardian's Signature _____________________________________ Date OFFICE USE ONLY Student ID # Date Distributed 00NCLB-B1 (Rev. 03/05 US) Date Received © 2005 TransACT Communications, Inc. P02028

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