Andale Elementary School

Please Fill Out The PreK Student Data Form Below

Child's First Name

Child's Middle Name

Child's Last Name

Child's Preferred Name (if different):

Child's Birth Date

Gender

Reaquired field: Male

Reaquired field: Female

Hispanic/Latino?

Reaquired field: yes

Reaquired field: no

Race (check all that apply)

Reaquired field: White

Reaquired field: Black or African American

Reaquired field: Asian

Reaquired field: American Indian or Alaska Native

Reaquired field: Native Hawaiian/Pac. Islander

Child resides with:

Reaquired field: Both Parents

Reaquired field: Mother

Reaquired field: Father

Reaquired field: Other

Has your child attended preschool before?

Reaquired field: yes

Reaquired field: no

If yes, please list name of preschool:

My child will attend Kindergarten at:

Reaquired field: Andale Elementary

Reaquired field: Other

Please list older siblings in K-12:

Please list school district student resides:

Does your child have an IEP?

Reaquired field: yes

Reaquired field: no

Mother's First & Last Name

Reaquired field: Mother's Address

Address

City

State / Province / Region

Zipcode Min: 1 Max: 5

Country

Home Phone if available

Mother's Cell Phone

Mother's Email

Mother's Employer

Mother's Work Phone #

Father's First & Last Name

Father's Address if different than Mother's Address

Address

City

State / Province / Region

Zipcode Min: 1 Max: 5

Country

Father's Cell Phone

Father's Email

Father's Employer

Father's Work Phone #

Medical Information (List history, diagnosis, surgeries, etc ...):

Does your child have any allergies? List food allergies, medication allergies, etc ... Include emergency instructions in case of exposure.

List any medications taken routinely or intermittently:

Physician Name:

Physician Phone Number:

Preferred Hospital:

My child is potty trained. No assistance is required. If no, please comment.

Reaquired field: yes

Reaquired field: no

Reaquired field: Other

Name all people dropping off or picking up your child from preschool:

Does your child have any special interests?

What are some things your child is really good at?

What would you like your child to learn in preschool?

Do we have your permission to share your child's picture on social media (facebook, twitter,instagram,school website) when posting student activities? No student will be named individually?

Reaquired field: yes

Reaquired field: no

Do we have your permission to publish your student's fall photo in our yearbook?

Reaquired field: yes

Reaquired field: no

Do we have your permission to publish your student's photo in print media such as local newspapers?

Reaquired field: yes

Reaquired field: no

Do we have your permission for your student's name and family information to be published in the school directory?

Reaquired field: yes

Reaquired field: no

Do we have your permission for your student to attend events within city limits of Andale by walking (Ex: to community library or park)? I will be notified of all events and have the right to deny participation.

Reaquired field: yes

Reaquired field: no

Is your child a dependent of active military duty (full-time)?

Reaquired field: yes

Reaquired field: no

Is your child a dependent of National Guard or Reserve Forces?

Reaquired field: yes

Reaquired field: no

Emergency Contact #1 First & Last Name (if parents are unavailable):

Emergency Contact #1 Relationship to Student:

Reaquired field: Grandparent

Reaquired field: Sibling

Reaquired field: Daycare

Reaquired field: Other Relative

Reaquired field: Other

Emergency Contact #1 Phone Number:

Emergency Contact #2 First & Last Name:

Emergency Contact #2 Relationship to Student:

Grandparent

Sibling

Daycare

Other Relative

Other

Emergency Contact #2 Phone Number:

Email a copy to

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Required Fields