Kindergarten Center - Enrollment Form

Please Fill Out The Enrollment Form Below

Child's Full Name

First Name:

Middle Name:

Last Name:

Birthdate (MM/DD/YYYY)

Gender

Female

Male

SOCIAL SECURITY NUMBER:

Hispanic/Latino Ethnicity

Yes

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:

City:

State:

Zip Code:

Mailing Address (If different than Physical/911)

Address:

City:

Zip Code:

State:

Parent/Guardian Information

Parent / Guardian 1

Name:

Relationship to Student:

Mailing Address

City / State / Zip Code

Primary Phone:

Text Message:

Email:

Employer

Work Phone

Student primarily resides with this Guardian

Yes

Parent Guardian 2

Name

Relationship to Student

Mailing Address

City / State / Zip

Primary Phone

Text Message:

Employer

Work Phone

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

Please list all siblings living in the home along with date of birth. If sibling is school age, please indicate grade and school attending.

Emergency Contact Information

List Emergency Contacts below with the required information. (In order for us to add emergency contacts, the following information is required for each contact: Full Name, Contact Phone Number, Mailing Address, City/State/Zip.)

List anyone who is ALLOWED to check out/pick up this child from school:

Physician:

Physician Phone Number

Has this child been expelled from school in any other school district or is the child a party to an expulsion hearing:

Yes

I hereby authorize the use of corporal punishment but will be notified prior to punishment being administered.

Yes

Signature

Parent/Guardian Signature

Email a copy to

optional

Required Fields

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