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OZARK Kindergarten
Enrollment Form
Fill Form out as
completely
as possible.
Please Fill Out The Enrollment Form Below
Child's Full Name
First Name:
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Middle Name:
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Last Name:
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Birthdate (MM/DD/YYYY)
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Gender
Female
Male
SOCIAL SECURITY NUMBER:
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Hispanic/Latino Ethnicity
Yes
No
Race
Please answer the following in accordance with standards issued by the US Dept of Education
PRIMARY RACE
American Indian or Alaska Native (A person having origins in any of the original peoples of North and South America, including Central America and who maintains tribal affiliation or community attachment)
Asian (A person having origins in any of the origial peoples of Far East, Southeast Asia, or the Indian subcontinent, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, Philippine Islands, Thailand and Vietnam)
Black or African American (A person having origins in any of the black racial groups of Aficia)
Native Hawaiin or Other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, other Pacific Islands)
White (A Person having origins in any of the origianl peoples of Europe, Middle East or North Africa)
ADDITIONAL RACES (check all that apply):
American Indian/ Alaska Native
Asian
Black
Native Hawaiian/Other Pacific Islander
White
Student Address
Physical/911
Address:
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City:
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State:
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Zip Code:
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Mailing Address (If different than Physical/911)
Address:
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City:
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Zip Code:
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State:
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Parent/Guardian Information
Parent / Guardian 1
Name:
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Relationship to Student:
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Mailing Address
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City / State / Zip Code
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Primary Phone:
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Text Message:
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Email:
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Employer
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Work Phone
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Student primarily resides with this Guardian
Yes
Parent Guardian 2
Name
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Relationship to Student
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Mailing Address
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City / State / Zip
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Primary Phone
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Text Message:
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Email
Employer
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Work Phone
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Student primarily resides with this Guardian
Yes
Additional Student Information
Travel Information
Travel to School
Bus
Parent / Guardian (includes walkers. child care vans, etc...)
Travel From School Copy
Bus
Parent / Guardian (includes walkers. child care vans, etc...)
PRE-SCHOOL PARTICIPATION
A - Arkansas Better Chance
E - Even Start
EC - Early Childhood
H - Headstart
NA - Not Applicable
C - 21st Century Community Learning
P - Private
PS- Public School
Other
Other
Is this child a dependent of an active or reserve member of a branch of the United States Armed Services, please select the branch below.
None
Active Duty - US Air Force
Active Duty - US Marines
Active Duty - US Navy
Active Duty - US Coast Guard
Active Duty - US Army
Reserves - US Marines
National Guard - US Army
Reservies - US Army
Reserves - US Navy
Reserves - US Air Force
National Guard - US Air Force
Parents serve in multiple branches
Please list all siblings living in the home along with date of birth. If sibling is school age, please indicate grade and school attending.
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Emergency Contact Information (contacts other than Parent/Guardian to be called in Case of an Emergency)
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List anyone who is ALLOWED to check out/pick up this child from school:
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Physician:
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Physician Phone Number
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Has this child been expelled from school in any other school district or is the child a party to an expulsion hearing:
Yes
No
I hereby authorize the use of corporal punishment but will be notified prior to punishment being administered.
Yes
No
************** Important Information Below ******************
Schedule an Appointment
You must call the Ozark Kindergarten Center to schedule an appointment for pre-screening. The phone number is (479) 667-3021
I understand I must call and schedule an appointment to complete the Kindergarten Registration Process.
Signature
Parent/Guardian Signature
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I agree that by typing my name in the "Parent/Guardian Signature" text box, that is my signature and I have completed this form truthfully.
Yes
No
Email a copy to
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Required Fields
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