School District of New Richmond 701 East Eleventh Street New Richmond, WI Fax

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1 School District of New Richmond 701 East Eleventh Street New Richmond, WI Fax Starting School Date: Site Assigned: 4-Year-Old Kindergarten Registration Check one: Entering 4K in Repeating 4K in Gender: F M Student's Legal Name: (First Name) (Middle Name) (Last Name) Address: (Street) (City/Town) (Zip) (County) Telephone Number: Resident of New Richmond School District Yes No Date of Birth: / / Place of Birth (City, County, State): Documentation of Date of Birth (Birth certificate required for 4K. Birth certificates will NOT be kept on file.) Immunization Records attached (Required for 4K) Ethnic Category Information: 1. Is this student Hispanic or Latino? (Check only one) Yes, Hispanic or Latino No, not Hispanic or Latino, go to question 2 2. Is this student: (Choose one or more. You must select at least one) American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Language(s) other than English spoken in the home: Select three (3) possible 4K sessions. Please indicate your preferences with a 1, 2, and 3. Every effort will be made to provide families with their first choice. Session assignments will be determined by the submitted registration and considered final. Assignments will not be changed without an extenuating circumstance as determined by the NR4K Director. See brochure or contact site director for wrap-around care and/or transportation information. Bear Buddies/Learning Station Preschool (M-Th) AM (8:15-11:30) PM (12:15-3:30) First Lutheran Church Preschool (M-Th,Occasional Fridays ) AM (8:15-11:00) PM (12:00-2:45 ) Hansen s Learning Center (M-Th) AM (8:00-11:00) New Richmond Area Centre-4K (M-Th) AM (8:30-11:30) PM (12:30-3:30) New Richmond CESA #11 Head Start (M, T, Th. & F) Full Day (8:30-2:30) Must meet financial qualification to attend Head Start. Please contact Head Start prior to selection. Sonshine Learning Center (M-Th) AM (8:15-11:30) PM (12:15-3:30) St. Mary s School Prekindergarten (M-Th) AM (8:00-11:00) PM (11:30-2:45) Parent/Guardian Signature: Date: Office Use ONLY Original Birth Certificate Verified by Date Immunization Records Attached: Yes No 3 Site Choices Selected: Yes No Rev

2 School District of New Richmond 701 East Eleventh Street New Richmond, WI Fax FAMILY INFORMATION Student s Name PRIMARY PARENT(s)/GUARDIAN(s) residing with student NAME: Relationship to student: (First Name) (Middle Initial) (Last Name) Cell Phone Number: Work Phone Number: Address: NAME: (First Name) (Middle Initial) (Last Name) Cell Phone Number: Relationship to student: Work Phone Number: Address: Are you living in temporary housing? No Yes If Yes: Living Arrangements: House Apartment Shelter Doubled up Other (please explain): Other children residing in this household: (list full name, date of birth, grade, school) SECONDARY PARENT/GUARDIAN NAME: (First Name) (Middle Initial) (Last Name) Cell Phone Number: Relationship to student: Work Phone Number: Address: Address: (Street) (City/Town) (State) (Zip) Rev

3 School District of New Richmond 701 East Eleventh Street New Richmond, WI Fax REGISTRATION INFORMATION Student s Name Has your child attended a screening for early childhood students such as Child Development Days? Yes No If yes: New Richmond Another Wisconsin School, name: Another State Results: Has your child been screened for vision? Yes No Has your child been screened for hearing? Yes No Has your child been enrolled in Early Childhood Special Education? Yes No If YES, please circle which service(s) they received: Speech/Language Occupational Therapy Physical Therapy Early Childhood Teacher Services Has your child been enrolled in any other special classes or programs in your previous school or community? Please check all that apply: Early Intervention: (B-3 Intervention) - List dates and school or provider: Early Childhood: Special Education (Student has an Individual Education Plan, IEP): List dates and school or provider: Occupational Therapy - List dates and school or provider: Physical Therapy - List dates and school or provider: Speech and Language - List dates and school or provider: _ Do you have concerns about your child s development? Please explain: In order for your child s registration to be accepted, please ensure the following three (3) items are completed: 1. Birth Certificate (Original only) presented for verification of birth date 2. Immunization form completed or records attached 3. Three (3) sessions selected Rev

4 HOME LANGUAGE SURVEY School District of New Richmond 701 East Eleventh Street New Richmond, WI Fax NAMES/GRADES OF ALL CHILDREN Name Age / Grade Name Age / Grade Relationship of Person Completing Survey Specify Directions: Check the correct response for each of the following questions and indicate other languages if appropriate. English Other Specify Lang. Lang. 1. What language did the child(ren) learn when she/he first began to talk? 2. What language does the family speak at home most of the time? 3. What language does the parent(s) speak to her/his child most of the time? 4. What language does the child speak to her/his parent(s) most of the time? 5. What language does the child hear and understand in the home? 6. What language does the child speak to her/his brothers/sisters? 7. What language does the child speak to her/his friends most of the time? 8. Can an adult family member or extended family member speak English? 9. Can an adult family member or extended family member read English? 10. Do the parents/guardians request oral and/or written communication from the school to be in English? If no, in what language? Yes No SIGNATURE Signature of Person Completing Survey Date Signed FOR STAFF COMPLETION TO BE COMPLETED FOR ALL NEW ELL STUDENTS ELL File Opened Yes No Today s Date ELL Test Date Test ELL Evaluator ELL Level Placement Created by: Melissa Moe, CESA 11 ELL Educational Consultant 01/13/16 Adapted from: Sample Survey, Institute for Cultural Pluralism, Lau General Assistance Center, San Diego State University, San Diego, CA [sic], 1976 Revised 1/13/2016

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