Kindergarten Center

Please Fill Out The Enrollment Form Below

Child's Full Name

First Name:

Middle Name:

Last Name:

Birthdate (MM/DD/YYYY)

Gender

Reaquired field: Female

Reaquired field: Male

SOCIAL SECURITY NUMBER:

Hispanic/Latino Ethnicity

Reaquired field: Yes

Reaquired field: No

Race

Please answer the following in accordance with standards issued by the US Dept of Education

PRIMARY RACE

Reaquired field: 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)

Reaquired field: 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)

Reaquired field: Black or African American (A person having origins in any of the black racial groups of Aficia)

Reaquired field: Native Hawaiin or Other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, other Pacific Islands)

Reaquired field: 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

Reaquired field: Bus

Reaquired field: Parent / Guardian (includes walkers. child care vans, etc...)

Travel From School Copy

Reaquired field: Bus

Reaquired field: Parent / Guardian (includes walkers. child care vans, etc...)

PRE-SCHOOL PARTICIPATION

Reaquired field: A - Arkansas Better Chance

Reaquired field: E - Even Start

Reaquired field: EC - Early Childhood

Reaquired field: H - Headstart

Reaquired field: NA - Not Applicable

Reaquired field: C - 21st Century Community Learning

Reaquired field: P - Private

Reaquired field: PS- Public School

Reaquired field: 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:

Reaquired field: Yes

Reaquired field: No

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

Reaquired field: Yes

Reaquired field: No

Signature

Parent/Guardian Signature

Email a copy to

optional

Required Fields

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