4K Registration Packet - Marshfield School District

School Year
REGISTRATION CARDMARSHFIELD SCHOOLS
School
Grade
Name of Student
Age
PLEASE PRINT
Sex: M
F
Date of Birth
(last)
(first)
(middle name)
Address
(street)
(city)
(mo.) (day) (year)
Phone
(township)
Race: (check all that apply) ___American Indian/Alaskan Native ___Asian __Black/African American___Native Hawaiian/Pacific Islander __White
Is this student Hispanic or Latino? (choose only one) ____No, not Hispanic or Latino ____Yes, Hispanic or Latino
Birth City
County
State
Father
Address
Mother
Address
Father’s Email Address
Country
Phone
Phone
Mother’sEmailAddress
(list emails only if can be used for school use)
Occupation of Father
Employer
Occupation of Mother
Employer
Is your child covered by any type of health insurance? Yes___ No ___This information will be shared with the appropriate school personnel.
Today’s Date
Signature of Parent
The School District of Marshfield does not discriminate on the basis of sex, race, religion, national origin, ancestry, creed, pregnancy, marital or parental status, sexual
orientation, or physical, mental, emotional, or learning disability or handicap in its education programs or activities, and complies with all requirements and regulations
pursuant to law. Student directory data (student name, address, phone number, email, and name of parent or guardian) may be released unless the parent or guardian
notifies
the Principal in writing that all or part of the data may not be released.
SCHOOL DISTRICT OF MARSHFIELDREGISTRATION
STUDENT'S NAME
Last
First
Middle Name
Record verifying birth:
_____ Birth Certificate
_____ Baptismal Certificate
OFFICE USE ONLY
Date of Birth
Month
Day
Male Female
Circle One
Year
Place of Birth
City
State
Father
County
Country
Mother
Number of children in family
Name
Student lives with:
Both parents
Date of Birth
Mother
Father
Other
If your child is called by a nickname, please spell it:
Though we realize that parents prefer the neighborhood location, there are some situations where placement
may occur at another 4K location in order to achieve equitable class size.
1st Preference 4K Site
Session: AM or PM or Either
2nd Preference 4K Site
Session: AM or PM or Either
Will your child be requiring transportation to or from school?
Yes or NO
*If you live within city limits or outside of the district please contact: Marshfield Bus Service. There is no fee
If you live in the country, or your child attends Head Start 4K.*
Every effort will be made to honor requests, but this preference is not a guarantee.
Neighborhood Schools
Session Times
ABC Child Care Center – Lincoln
7:45AM – 10:50 AM
Bright Horizons – Grant
11:40 AM – 2:45 PM
Child Care Centers of Marshfield – Madison
Grace Lutheran – Nasonville (4K AM session only)
Tiny Tiger Intergenerational Center – Madison
YMCA – Pied Piper Child Development Center – Grant (No child care offered)
Wood County Head Start- (Prequalification Required)
SCHOOL DISTRICT OF MARSHFIELD, MARSHFIELD, WISCONSIN
SPECIAL NEEDS DATA
To enable us to identify and more immediately service students with possible special needs, please provide the following
information at the time of registration.
Child's name
Birth date
School
1. Has your child ever been referred for a disability?
2. Does your child have a disability?
yes
yes
Grade
no If yes, when
no If yes, what
3. Has your child ever received special education services?
a)
Age
yes
no If yes, please indicate which one(s):
Early Childhood (EC)
b) Learning Disabilities (LD)
c)
Emotionally/Behavioral Disability (ED/EBD)
d) Cognitive Disabilities
e)
Speech Therapy
f)
Occupational Therapy (OT)
g)
Physical Therapy (PT)
h) Adaptive Physical Education (Specially Designed Physical Education)
i)
Hearing Impaired
j)
Vision Impaired
k)
Physically Disabled
l)
Other(s): Please list and explain
4. Has your child been diagnosed as having Attention Deficit Disorder (ADD)?
5. Has your child had the service of a School Guidance Counselor?
6. Has your child received school social work services?
7. Has your child received Chapter I (Title I) services?
yes
yes
yes
yes
no
no
no
no
8. Has your child received any alcohol and drug services through the schools?
yes
no If yes, please explain
9. Has your child required/received special services/treatment/assessment (not special education) of any kind from the
school?
yes
no If yes, please explain
Signature of Parent/Guardian
Date
HOME LANGUAGE SURVEY - SCHOOL DISTRICT OF MARSHFIELD
TO BE COMPLETED FOR ALL STUDENTS NEW TO THE DISTRICT
Student’s Name
Grade
Relationship of Person Completing Survey
Assigned School (circle one)
 Mother
 Father
Child’s Country of Birth
 Guardian
 Other
G L M N W
4K Site (circle one)
Number of years in U.S.
MS HS
Has child been enrolled in US schools for 3 consecutive years?
ABC BH CCCM CCFK
Please list the date student first enrolled in US school.
HS PP TT
Directions:
1.
2.
Check the correct response for each of the following questions and indicate other languages, if
appropriate.
English Language(s) Spoken
Dialect
What language does the child speak to her/his friends


most of the time?
What language do family members or extended family
members speak most of the time?
3.
What language do family members read?
4.
In what language do the parents/guardians request oral
and/or written communication from the school?






STOP HERE IF ENGLISH IS THE PRIMARY LANGUAGE SPOKEN BY THE CHILD
English
5.
6.
7.
8.
Language(s) Spoken
What language did the child learn when she or he first
began to talk?


In what language do the parent(s) speak to this child
most of the time?


What language does the child hear and understand in
the home?


What language does the child speak to her/his
brothers/sisters most of the time?


Dialect
Send original to Director of Instruction, Central Office, as soon as new student registers. Keep one copy for
Principal’s file.
ESL File Opened
 Yes
 No
ESL Evaluator
FOR STAFF COMPLETION
ESL Test Date
Today’s Date
Test
ESL Level
Placement
GL
HEALTH GUIDANCE RECORD
Name
Address
Telephone
Sex:
School
Birth Date
Male Female Physician
Dentist
Mother's Name
Occupation
Father's Name
Occupation
Brothers: Ages
Sisters: Ages
MEDICAL HISTORY (State years in which each occurred. If current problems, please note)
Allergy (Specify)
___
Asthma
Bronchitis or Pneumonia
Diabetic
Ear Infections
Enuresis (bed wetting/daytime dryness)
Speech concerns
Bowel problems
Kidney Infection
Whooping Cough
Heart Conditions
Frequent cold or sore throats
Chickenpox
Epilepsy-seizures
Vision or hearing concerns
Frequent nose bleeds
Other injuries, illnesses or operations (Specify)
Is your child on medications?
Yes
No If yes, which medications?
COMMENTS:
Date
Signed
Parent or Guardian
Children of Divorced/Separated Parents Enrollment Form
Student Name
Name of Enrolling Parent or Guardian
Address
Email address
City
State
Work Number
Telephone Number
Cell Number
Please check one:




I have full custody and primary physical placement of the student.
I have joint custody and shared physical placement of the student as described in the most recent Court Order of
custody and placement (attach Court Order).
I have joint custody and primary placement of the student as described in the most recent Court Order of custody
and placement (attach Court Order).
I do not have any of the above arrangements. Please see the most recent Court Order of custody and placement
for details (attach Court Order).
Name of Court having jurisdiction over the above student
Full Name of Court
City
State
List the other party to the action affecting the student:
Name
Address
Telephone Number
City
State
Does the most recent Court Order curtail or restrict the rights and privileges of the other parent to be kept
advised of the student’s school progress and school activities or participation?
 Yes (attach Court Order)
 No
Does the most recent Court Order definitely prohibit the school to release the student to the other parent?
 Yes (attach Court Order)
 No
Parent/Guardian Signature
Date
*If no current court orders are provided, the school will assume both parents have full parental rights and
responsibilities.