Ravena-Coeymans-Selkirk Central School

Pre-Kindergarten Application 2008-09

For Official Use:

Student #___________

Family #___________

Date Rec.__________

___ Birth Certificate

___ Proof of Residency

___ Free & Reduced Lunch

___ Custody Papers

___ Social Security Card

Child’s Name

                                                                   DOB

               Last               First                  Middle

Phone Number                            Male          Female       Ethnic Group      

Residence Address:                            Mailing Address:

Exact Location and Description of Residence                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       

Mother’s Name                    Occupation                        Work Place                    Work Phone                   Home Phone                 

Father’s Name         Occupation                        Work Place                    Work Phone                   Home Phone

Child Lives With:   Both Parents           Mother            Father            Other                         

If Other:

Guardian’s Name                                                            Phone Number

Address

Affidavits Given       A          B    Affidavits Received   A          B

Are there any restrictions regarding releasing your child to his or her parents?         Yes        No

(If yes, please use additional paper for explanation and attach copy of legal document.)

Brothers and Sisters:

Names (first and last)               Birthdate                School               Residence if not at home

In an Emergency:  If your child becomes sick and you are not available, please notify                                                                                                                                                                    

Name                                                  Relationship                     Phone Number

Student Pickup and Drop-off (Where child will get on and off the bus, if not at home)

Sitter: Pickup               Drop-off                   Name                              Phone Number 

Sitter Address                                                      Exact Location

Parent/Guardian Signature                                                                Date

COMPLETE BOTH SIDES ALONG WITH THE FREE AND REDUCED LUNCH FORM

CHILD’S HISTORY

Child’s Name                                                                           Date of Birth

Child’s Birth Weight                                lbs.                            ozs.

Delivery:                        Normal                       Premature

Any Complications?

HEALTH ISSUES:

Problems?

Frequent Ear Infections                      Sore Throats                    Others

Any difficulty hearing or seeing?

Allergies

DEVELOPMENT:

Age Child Began -           Rolling Over                     Sitting                    Crawling               

Walking                            Dress Themselves

Do you think your needs help with:

Fine Motor Skills (picking up small objects, drawing etc.)

Large Motor (jumping, skipping, etc.)

When did your child start talking?

Can you easily understand him/her?

Can others?

Any problems?

Repeating sounds or words (stuttering)?

Do you feel your child needs help with speech?

Has your child had any screenings or evaluations done?

Services, recommended (speech, OT, PT, Seit)?

What services is your child receiving?

Where?

SOCIAL/BEHAVIORS

What is your child’s favorite thing to do?

How does your child respond to changes in routine?

Does your child prefer playing alone or with others?

When alone, what keeps your child busy?

Does he/she get along with brothers/sisters?

Does he/she follow directions?

What upsets your child?

When your child is upset, how does he/she behave?

What works best at those times?

Can your child separate from family easily?

Any preschool                  , if yes, where?

FAMILY EDUCATION

Mother’s Maiden Name                                      Father’s Name

Date of Birth                                                    Date of Birth

Highest Grade of School Completed (circle one)   Highest Grade of School Completed (circle one)

1  2  3  4  5  6  7  8  9  10  11  12  GED                      1  2  3  4  5  6  7  8  9  10  11  12  GED

Business or Vocational                                      Business or Vocational  

Some College beyond High School                                  Some College beyond High School

College Degree                                                          College Degree