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

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1 701 East Eleventh Street New Richmond, WI Fax Starting School Date: Site Assigned: 4-Year-Old Kindergarten Registration Office Use Only: Documentation of DOB Immunization Records Attached Three (3) session choices Check one: Entering 4K in Repeating 4K in Gender: F M STUDENT S LEGAL NAME: (First Name) (Middle Name) (Last Name) HOME PHONE NUMBER: ADDRESS: (Street) (City/Town) (State) (Zip) MAILING ADDRESS (if different from above): New Richmond School District Resident: Yes No If No, have you applied for Open Enrollment? Yes No County of Residence: 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. Site/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 directors 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 Childcare Center (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. St. Mary s School Prekindergarten (M-Th) AM (8:00-11:00) PM (11:30-2:45) Sonshine Learning Center (M-Th) AM (8:15-11:30) PM (12:15-3:30) Parent/Guardian Signature: Date: Rev

2 701 East Eleventh Street New Richmond, WI Fax FAMILY REGISTRATION INFORMATION STUDENT S FULL NAME CUSTODIAL PARENT(s) / GUARDIAN(s) RESIDING WITH STUDENT Legal First Name M.I. Legal Last Name Relationship Cell Phone # Work Phone # address: Are you living in temporary housing? Yes No If Yes: Living Arrangements: House Apartment Shelter Doubled up Other (please explain): Student resides primarily with: Father & Mother Mother Only 50/50 Physical Placement Mother & Stepfather Father Only Other Father & Stepmother Guardian Is there a step-parent in the household? Yes No If yes, print name of step-parent I would like the step-parent residing in my household to have parental rights for school purposes. Yes No Biological parent signature required Date List ALL children residing in the household: (include all children who are 18 years of age or younger) First Name M.I. Last Name Gender Birth Date Grade School OTHER GUARDIAN / SECOND MAILING (50/50 or Non-Custodial Parent) Legal First Name M.I. Legal Last Name Relationship Cell Phone # Work Phone # address: House # Street Name Apt # City State Zip Home Phone # Rev

3 701 East Eleventh Street New Richmond, WI Fax REGISTRATION INFORMATION STUDENT S FULL 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 Parent/Guardian Home Language Survey NAMES/GRADES OF ALL CHILDREN Name Age / Grade Name Age / Grade Relationship of Person Completing Survey Mother Father Guardian Other 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? Yes No 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? 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 08/02/10 Adapted from: Sample Survey, Institute for Cultural Pluralism, Lau General Assistance Center, San Diego State University, San Diego, CA [sic], 1976 Revised

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