dover union free school district 2368 route 22 registrar ......dover plains, ny 12522. welcome to...

Welcome to the Dover Union Free School District.

To begin the registration process please call (845).877.5700 ext. 1289. The District will mail the

registration packet to you in advance to minimize appointment time or parents/guardians can

visit the District website at www.doverschools.org to obtain the required forms.

Parents/Guardians are REQUIRED to provide the following documents at the time of

registration:

Original Birth Certificate

Proof of Residency (rental agreement, contract of sale, utilities bill, etc.)

Immunizations/Physical

Driver’s License (or other VALID photo id)

Court Papers (i.e. Foster Care, Proof of Guardianship, custody papers, if applicable)

Thank You,

Robin Conklin

Registrar

Dover Union Free School District 2368 Route 22

Dover Plains, NY 12522 Registrar Office (845) 877-5700 ext. 1289

http://www.doverschools.org/

Rev. 11/15/16

NOTE TO SCHOOLS/LEAS: Please assist students and families filling out this form. The form should be included at

the top page of registration materials that the district shares with families. Do not simply include this form in the

registration packet, because if the student qualifies as residing in temporary housing, the student is not required to

submit proof of residency and other required documents that may be part of the registration packet.

HOUSING QUESTIONNAIRE

Name of LEA: Dover Union Free School District

Name of School:

Name of Student:

Last First Middle

Gender: � Male Date of Birth: / / Grade: ID#:

� Female Month Day Year (preschool-12) (optional)

Address: Phone:

The answer you give below will help the district determine what services you or your child may be able to

receive under the McKinney-Vento Act. Students who are protected under the McKinney-Vento Act are

entitled to immediate enrollment in school even if they don’t have the documents normally needed, such

as proof of residency, school records, immunization records, or birth certificate. Students who are

protected under the McKinney-Vento Act may also be entitled to free transportation and other services.

Where is the student currently living? (Please check one box.)

In a shelter

With another family or other person because of loss of housing or as a result of economic hardship

(sometimes referred to as “doubled-up”)

In a hotel/motel

In a car, park, bus, train, or campsite

Other temporary living situation (Please describe):

In permanent housing

Print name of Parent, Guardian, or Signature of Parent, Guardian, or

Student (for unaccompanied homeless youth) Student (for unaccompanied homeless youth)

Date

If ANY box other than “In Permanent Housing” is checked, , then the student/family should be immediately

referred to the MV Liaison. In such cases, proof of residency and other documents normally needed for

enrollment are not required and the student is to be immediately enrolled. After the student has been

enrolled, the district/school must contact the previous district/school attended to request the student's

educational records, including immunization records, and the enrolling district's LEA liaison must help the

student get any other necessary documents or immunizations.

NOTE TO SCHOOLS/LEAS: If the student is NOT living in permanent housing, please ensure that a

Designation Form is completed.

Dover Union Free School District Student Registration Form

STUDENT INFORMATION (Student’s Legal Name)

First: Middle: Last:

Nickname: Birthdate:

_______/_______/_______

Gender:

Male Female

Birthplace Age:

City: State: Country:

Student’s Primary Language: Secondary Language: Language spoken at home:

Ethnicity: Hispanic Non-Hispanic

Race: (choose all that apply)

White/Caucasian Asian Black/African American

American Indian/Alaskan Native Native Hawaiian/Other Pacific Islander

Enrolling in grade: Has the student attended Dover before? YES NO

Grades attended: ________

Previous School Attend: Retained (repeated a grade)? If so, what grade? ______

YES NO

Is this child currently suspended from school for

gross misconduct? YES NO

If YES, did the suspension involve

drugs, weapons or alcohol? YES NO

Received special services/programs: (speech/counseling/remedial math or reading)

Does your child have a IEP or 504 plan?

YES NO

Which one?

IEP 504 Plan

Any special concerns the teacher/nurse/counselor

should be aware of? YES NO

If yes, list: ____________________________________

______________________________________________

PRIMARY HOUSEHOLD INFORMATION (Student resides with )

ADULT 1Name:

Relationship to student:

Birthdate:

______/_____/________

Place of Birth: Primary Language:

Home Phone: Cell Phone: Work Phone:

Address:

Street City/town State Zip

E-Mail: Place of Employment:

ADULT 2Name:


Birthdate:

_____/______/_______


Cell Phone: Work Phone:


Do you own or rent? Own Rent

Family Status:

Married Divorced Separated Single

Widowed Other_________________________

Legal custody? YES NO Do you have custody papers? YES NO

Please indicate custody type:

Sole Joint 50/50 No Rights

Do you have an Order of Protection? Yes No

If so, against who? ______________________________

Other parent student DOES NOT RESIDE with: (if applicable)

Send Mailings? Yes NO

ADULT 1Name:


Birthdate:

_______/_______/_______


Cell Phone: Work Phone:


Address:

Street City/town State Zip

SIBLING INFORMAITON

Name:___________________________School:________________Gender:__________DOB________




EMERGENCY CONTACT INFORMATION In case parent/guardian cannot be reached, what LOCAL resident(s) may we call?

Name: ____________________________ Relation to student:____________________

Home: (___)_________________ Cell: (___)________________ Work Phone (___)____________

Name: ____________________________ Relation to student:____________________

Home: (___)_________________ Cell: (___)________________ Work Phone (___)____________

Is there anyone to whom you do not want your child released? (indicate below)

Name: _______________________________________ Relationship to student:__________________

Is the child living with someone other than parents? YES NO

If NO skip to section II then sign & date. If YES, please complete section I

Section I

1. If the child is living with someone other than parents and has been placed there by order of court or

government agency, please answer the following questions:

a. Which court or agency? ______________________________________________________________

b. When was the child placed? ___________________________________________________________

c. Is the placement to end at a specific time? No Yes When? __________________

2. If the child is living with someone other than parents, but has not been placed there by order of court or

government agency:

a. State the relationship of that person to the student: _________________________________________

b. Why is the student living with that person(s)? Provide as complete answer as possible. Use additional

pages if needed.

__________________________________________________________________________________________

__________________________________________________________________________________________

_________________________________________________________________________________

c. When did the student begin living with this person? ________________________________________

d. How long will the student live with this person? ___________________________________________

e. Does this person have the authority to discipline the student? No Yes

f. If the answer to “e” is NO, who has the authority to discipline the student? ________________________

g. With whom did the student reside last summer? _____________________________________________

h. Whom should the school notify if the student becomes ill or is injured at school?____________________

i. Who will attend parent conferences at the school? ___________________________________________

j. Who is authorized to receive grade cards? __________________________________________________

k. Whom should the school notify if the student is disciplined at school? ___________________________

l. Does the student live part-time with the parents? No Yes

m. Where did the student attend school last year? ____________________________________________

Section II Please provide TWO proofs of residency:

Category I – PROVIDE AT LEAST ONE OF THE FOLLOWING DOCUMENTS:

_____ The most recent real estate tax bill for my residence showing me as the taxpayer

_____ Signed lease for my residence

_____ A closing statement for the purchase of my residence

_____ Truth in Lending form from closing packet

_____ Warranty Deed from closing packet

_____ Completed and notarized Landlord Affidavit (Landlord must show as owner on Town of Dover Parcel Access)

_____ Gas or electric bill

_____ Home/apartment insurance certificate

Category II – PROVIDE AT LEAST ONE OF THE FOLLOWING DOCUMENTS: _____ Driver’s license

_____ Passport

_____ Other photo ID (Please Specify) ________________________________________________

Warnings and Affirmation:

New York has made it a crime, punishable by imprisonment and fine, to knowingly or willfully present any

false information regarding the residency of a student for purposes of enabling that student to attend on a

tuition-free basis or to knowingly enroll or attempt to enroll a student on a tuition-free basis when the student is

known to be a non-resident of the District. The School District will seek prosecution to the full extent of the

law of any person who the district believes has committed any residency-related crime. Additionally, a civil

lawsuit may be initiated by the School District.

I affirm that I am a resident of this District and that the information presented in this Affidavit or in connection

with any investigation of my residency of the student is true, complete, and accurate.

_______________________________________________ ___________________________

Signature of Parent or Guardian Date

Family Educational Rights and Privacy Act (FERPA) The Family Educational Rights and Privacy Act (FERPA), a Federal law, requires that Dover Union Free School

District, with certain exceptions, obtain your written consent prior to the disclosure of personally identifiable

information from your child’s education records. However, Dover Union Free School District may disclose

appropriately designated "directory information" without written consent, unless you have advised the District to the

contrary in accordance with District procedures. The primary purpose of directory information is to allow the Dover

Union Free School District to include this type of information from your child’s education records in certain school

publications. Examples include:

A playbill, showing your student’s role in a drama production;

The annual yearbook;

Honor roll or other recognition lists;

Graduation programs; and

Sports activity sheets, such as for wrestling, showing weight and height of team members.

Directory information, which is information that is generally not considered harmful or an invasion of privacy if

released, can also be disclosed to outside organizations without a parent’s prior written consent. Outside

organizations include, but are not limited to, companies that manufacture class rings or publish yearbooks. In

addition, two federal laws require local educational agencies (LEAs) receiving assistance under the Elementary and

Secondary Education Act of 1965 (ESEA) to provide military recruiters, upon request, with three directory

information categories – names, addresses and telephone listings – unless parents have advised the LEA that they do

not want their student’s information disclosed to military recruiters without their prior written consent.1

If you do not want Dover Union Free School District to disclose directory information from your child’s education

records without your prior written consent, you must notify the District in writing.

Dover Union Free School District has designated the following information as directory information:

I have read and understand the above information as it pertains to my child:

_______________________________________ __________________

Parent/Guardian Signature Date

- Student’s name- Address- Telephone listing- Electronic mail address- Photograph- Date and place of birth- Major field of study

- Dates of attendance- Grade level Participation in officially

recognized activities and sports- Weight and height of members of athletic

teams- Degrees, honors, and awards received- The most recent educational agency or

institution attended

1 These laws are: Section 9528 of the ESEA (20 U.S.C. 7908), as amended by the No Child Left Behind

Act of 2001 (P.L. 107-110), the education bill, and 10 U.S.C. 503, as amended by section 544, the

National Defense Authorization Act for Fiscal Year 2002 (P.L. 107-107), the legislation that provides

funding for the Nation’s armed forces.


Dover Plains, NY 12522

Dover Union Free School District

2368 Route 22

Dover Plains, NY 12522

Registrar Office (845) 877-5700

Dear Parent or Guardian:

The New York State Education law requirements have changed in regards to the years in which

students are mandated to have health examinations on file. The requirements are now Kindergarten, Grades 1, 3, 5, 7, 11, all students participating in sports, as well as ALL new entrants. Your child’s health

examination may be given by your family physician. Your family physician has a more complete understanding of your child, can interpret his findings directly to you, and assist you in carrying out any

recommendations that may be indicated. Under new law, dental health certificates are also being recommended .The dental exam must be completed by your dentist. The school has a dental program

for basic routine cleanings and sealants. (Please note, schools do not offer dental exams).

We respectfully urge, therefore, that you take your child to your family physician and have the

ANNUAL HEALTH EXAMINATION RECORD and DENTAL HEALTH CERTIFICATE filled out and returned when the child enters school.

We are asking that all statements from the private physician and dentist be turned into the Health Office. Deadlines for physicals and vaccinations under new laws is within 14 days of the first day

of school. If a student is on a vaccine catch up schedule please discuss with the school nurse.

THE FOLLOWING VACCINATIONS ARE REQUIRED AND MANDATORY before a child enters or transfers to

our school district:

- 3 doses of Hepatitis B - 5 doses of DTaP, DTP* (some exceptions apply)

- 4 doses of Polio vaccine (some exceptions apply) - 2 doses of MMR vaccine

- 2 doses of Varicella vaccine

Please call the School Nurse with any questions:

Heidi Johnson (WES) 845-877-5721 Rachel MacLoughlin (DES) 845-877-5731

Andrea Mina (DMS) 845-877-5741

Kathleen Glynn (DHS) 845-877-5751

Sincerely,

Michael Tierney Michael Tierney

Superintendent of Schools Dover Union Free School District

Rev. 5/4/2018 Page 1 of 2

REQUIRED NYS SCHOOL HEALTH EXAMINATION FORM TO BE COMPLETED IN ENTIRETY BY PRIVATE HEALTH CARE PROVIDER OR SCHOOL MEDICAL DIRECTOR

Note: NYSED requires a physical exam for new entrants and students in Grades Pre-K or K, 1, 3, 5, 7, 9 & 11; annually for interscholastic sports; and working papers as needed; or as required by the Committee on Special Education (CSE) or

Committee on Pre-School Special education (CPSE).

STUDENT INFORMATION

Name: Sex: M F DOB:

School: Grade: Exam Date:

HEALTH HISTORY

Allergies ☐ No

☐ Yes, indicate type

☐Medication/Treatment Order Attached ☐ Anaphylaxis Care Plan Attached

☐ Food ☐ Insects ☐ Latex ☐Medication ☐ Environmental

Asthma ☐No

☐ Yes, indicate type

☐Medication/Treatment Order Attached ☐ Asthma Care Plan Attached

☐ Intermittent ☐ Persistent ☐ Other : ___________________________

Seizures ☐ No ☐Medication/Treatment Order Attached ☐ Seizure Care Plan Attached

☐ Yes, indicate type ☐ Type: __________________________ Date of last seizure: ______________

Diabetes ☐ No ☐Medication/Treatment Order Attached ☐ Diabetes Medical Mgmt. Plan Attached

☐ Yes, indicate type ☐Type 1 ☐ Type 2 ☐ HbA1c results: ____________ Date Drawn: _____________Risk Factors for Diabetes or Pre-Diabetes:

Consider screening for T2DM if BMI% > 85% and has 2 or more risk factors: Family Hx T2DM, Ethnicity, Sx Insulin Resistance, Gestational Hx of Mother; and/or pre-diabetes.

Hyperlipidemia: ☐ No ☐ Yes Hypertension: ☐ No ☐ Yes

PHYSICAL EXAMINATION/ASSESSMENT

Height: Weight: BP: Pulse: Respirations:

TESTS Positive Negative Date Other Pertinent Medical Concerns

PPD/ PRN ☐ ☐ One Functioning: ☐ Eye ☐ Kidney ☐ Testicle

Sickle Cell Screen/PRN ☐ ☐ ☐ Concussion – Last Occurrence: __________________________

Lead Level Required Grades Pre- K & K Date ☐Mental Health: ________________________________

☐ Other:☐ Test Done ☐ Lead Elevated > 10 µg/dL

☐ System Review and Exam Entirely Normal

Check Any Assessment Boxes Outside Normal Limits And Note Below Under Abnormalities

☐ HEENT ☐ Lymph nodes ☐ Abdomen ☐ Extremities ☐ Speech

☐ Dental ☐ Cardiovascular ☐ Back/Spine ☐ Skin ☐ Social Emotional

☐ Neck ☐ Lungs ☐ Genitourinary ☐ Neurological ☐Musculoskeletal

☐ Assessment/Abnormalities Noted/Recommendations: Diagnoses/Problems (list) ICD-10 Code

_________________________ _____________

_________________________ _____________

_________________________ _____________

☐ Additional Information Attached _________________________ _____________

Rev. 5/4/2018 Page 2 of 2

Name: DOB:

SCREENINGS

Vision Right Left Referral Notes

Distance Acuity 20/ 20/ ☐ Yes ☐ No

Distance Acuity With Lenses 20/ 20/

Vision – Near Vision 20/ 20/

Vision – Color ☐ Pass ☐ Fail

Hearing Right dB Left dB Referral

Pure Tone Screening ☐ Yes ☐ No

Scoliosis Required for boys grade 9 Negative Positive Referral

And girls grades 5 & 7 ☐ ☐ ☐ Yes ☐ No

Deviation Degree: Trunk Rotation Angle:

Recommendations:

RECOMMENDATIONS FOR PARTICIPATION IN PHYSICAL EDUCATION/SPORTS/PLAYGROUND/WORK

☐ Full Activity without restrictions including Physical Education and Athletics.

☐ Restrictions/Adaptations Use the Interscholastic Sports Categories (below) for Restrictions or modifications

☐ No Contact Sports Includes: baseball, basketball, competitive cheerleading, field hockey, football, ice hockey, lacrosse, soccer, softball, volleyball, and wrestling

☐ No Non-Contact Sports Includes: archery, badminton, bowling, cross-country, fencing, golf, gymnastics, rifle, Skiing, swimming and diving, tennis, and track & field

☐ Other Restrictions:

☐ Developmental Stage for Athletic Placement Process ONLY

Grades 7 & 8 to play at high school level OR Grades 9-12 to play middle school level sports

Student is at Tanner Stage: ☐ I ☐ II ☐ III ☐ IV ☐ V

☐ Accommodations: Use additional space below to explain

☐ Brace*/Orthotic ☐ Colostomy Appliance* ☐ Hearing Aids

☐ Insulin Pump/Insulin Sensor* ☐Medical/Prosthetic Device* ☐ Pacemaker/Defibrillator*

☐ Protective Equipment ☐ Sport Safety Goggles ☐ Other:*Check with athletic governing body if prior approval/form completion required for use of device at athletic competitions.

Explain: _____________________________________________________________________________

MEDICATIONS

☐Order Form for Medication(s) Needed at School attached

List medications taken at home:

IMMUNIZATIONS

☐ Record Attached ☐ Reported in NYSIIS Received Today: ☐ Yes ☐ No

HEALTH CARE PROVIDER

Medical Provider Signature: Date:

Provider Name: (please print) Stamp:

Provider Address:

Phone:

Fax:

Please Return This Form To Your Child’s School When Entirely Completed.

Dental Health Certificate Parent/Guardian: Please complete Section 1 and take the form to your dentist/dental hygienist for an assessment. Request your dentist/dental hygienist to fill out Section 2. Return the completed form to your child’s teacher as soon as possible.

Section 1. To be completed by Parent or Guardian (Please Print)

Child’s Name: Last First Middle

Birth Date: / / Month Day Year

Sex: Male Female

Will this be your child’s first visit to a dentist? Yes No

School: Name Grade

Section 2. To be completed by the Dentist/Dental Hygienist

I. Oral Health Status (check all that apply)

Yes No Caries Experience/Restoration History – Has the child ever had a cavity (treated or untreated?

[A filling (temporary/permanent) OR a tooth that is missing because it was extracted as a result of caries OR an open cavity].

Yes No Untreated Caries – Does this child have an open cavity?

[At least ½ mm of tooth structure loss at the enamel surface. Brown to dark-brown coloration of the walls of the lesion. These criteria apply to pits and fissure cavitated lesions as well as those on smooth tooth surfaces. If retained root, assume that the whole tooth was destroyed by caries. Broken or chipped teeth, plus teeth with temporary fillings, are considered sound unless a cavitated lesion is also present].

Yes No Dental Sealants Present

Yes No Soft Tissue Pathology

Yes No Malocclusion

II. Treatment Needs (check all that apply)

No need for Treatment

Urgent Treatment – abscess, nerve exposure, advanced disease state, signs or symptoms that include pain, infection, or swelling

Restorative Care – amalgams, composites, crowns, etc.

Preventive Care – sealants, fluoride treatment, prophylaxis, mouthguard etc.

Other – periodontal, orthodontic treatments

Please note _____________________________________________________________

The Dental Health condition of ________________________ on _______________________ (date of exam) Check one:

Yes, The student listed above is in fit condition of dental health to permit him/her attendance at the public schools.

No, The student listed above is not in fit condition of dental health to permit him/her attendance at the public schools.

Dentist’s Name and Address (Please Print or Stamp): Dentist/Dental Hygienist Signature:

Date of Exam: / /

* The dental health condition of the student when the exam is made andthe date of exam shall not be more than 12 months prior to thecommencement of the school year in which the exam is requested.

1 ENGLISH

Dear Parent or Guardian: In order to provide your child with the best possible education, we need to determine how well he or she understands, speaks, reads and writes in English, as well as prior school and personal history. Please complete the sections below entitled Language Background and Educational History. Your assistance in answering these questions is greatly appreciated. Thank you.

STATE EDUCATION DEPARTMENT / THE UNIVERSITY OF THE STATE OF NEW YORK / ALBANY, NY 12234 Office of P-12

Lissette Colón-Collins, Assistant Commissioner

Office of Bilingual Education and World Languages

55 Hanson Place, Room 594 89 Washington Avenue, Room 528EB

Brooklyn, New York 11217 Albany, New York 12234

Tel: (718) 722-2445 / Fax: (718) 722-2459 (518) 474-8775 / Fax: (518) 474-7948

Home Language Questionnaire (HLQ)

H O M E L A N G U A G E C O D E

Language Background (Please check all that apply.)

1. What language(s) is(are) spoken in the student’s homeor residence?

English Other

specify

2. What was the first language your child learned? English Other

_________________________________________ specify

3. What is the Home Language of each parent/guardian? Mother Fatherspecify specify

Guardian(s)specify

4. What language(s) does your child understand? English Other

specify

5. What language(s) does your child speak? English Other Does not speak

specify

6. What language(s) does your child read? English Other Does not read

specify

7. What language(s) does your child write? English Other Does not write

specify

TTHHIISS SSEECCTTIIOONN TTOO BBEE CCOOMMPPLLEETTEEDD BBYY DDIISSTTRRIICCTT IINN WWHHIICCHH SSTTUUDDEENNTT IISS RREEGGIISSTTEERREEDD::

Please write clearly when completing this section. S T U D E N T N A M E :

First Middle Last

D A T E O F B I R T H : G E N D E R :

Male Female Month Day Year

P A R E N T / P E R S O N I N P A R E N T A L R E L A T I O N I N F O :

Last Name First Name Relation to Student

S C H O O L D I S T R I C T I N F O R M A T I O N : S T U D E N T I D N U M B E R I N N Y S S T U D E N T

I N F O R M A T I O N S Y S T E M :

District Name (Number) & School Address

2 ENGLISH

Home Language Questionnaire (HLQ)—Page Two

Relationship to student: Mother Father Other:

Educational History

8. Indicate the total number of years that your child has been enrolled in school _____________

9. Do you think your child may have any difficulties or conditions that affect his or her ability to understand, speak, read or write inEnglish or any other language? If yes, please describe them.

Yes* No Not sure *If yes, please explain:____________________________________________________________________________

How severe do you think these difficulties are? Minor Somewhat severe Very severe

10a. Has your child ever been referred for a special education evaluation in the past? No Yes* *Please complete 10b below

10b. *If referred for an evaluation, has your child ever received any special education services in the past? No Yes – Type of services received: .

Age at which services received (Please check all that apply):

Birth to 3 years (Early Intervention) 3 to 5 years (Special Education) 6 years or older (Special Education)

10c. Does your child have an Individualized Education Program (IEP)? No Yes

11. Is there anything else you think is important for the school to know about your child? (e.g., special talents, health concerns, etc.)

12. In what language(s) would you like to receive information from the school? _________________________________________________

Month: Day: Year:

Signature of Parent or of Person in Parental Relation Date

OFFICIAL ENTRY ONLY - NAME/POSITION OF PERSONNEL ADMINISTERING HLQ

NAME: POSITION:

IF AN INTERPRETER IS PROVIDED, LIST NAME, POSITION AND CREDENTIALS:

NAME/POSITION OF QUALIFIED PERSONNEL REVIEWING HLQ AND CONDUCTING INDIVIDUAL INTERVIEW

NAME: POSITION:

ORAL INTERVIEW NECESSARY: NO YES

**DATE OF INDIVIDUAL INTERVIEW:

OUTCOME OF

INDIVIDUAL

INTERVIEW:

ADMINISTER NYSITELL

ENGLISH PROFICIENT

REFER TO LANGUAGE PROFICIENCY TEAMMO DAY YR.

NAME/POSITION OF QUALIFIED PERSONNEL ADMINISTERING NYSITELL

NAME: POSITION:

DATE OF NYSITELLADMINISTRATION:

PROFICIENCY LEVEL

ACHIEVED ON

NYSITELL: ENTERING EMERGING TRANSITIONING EXPANDING COMMANDING

MO. DAY YR.

FOR STUDENTS WITH DISABILITIES, LIST ACCOMMODATIONS, IF ANY, ADMINISTERED IN ACCORDANCE WITH IEP PURSUANT TO CSE RECOMMENDATION:


Dover Plains, NY 12522 (845) 877-5700

Bus Company (845) 877-3476

Student Information: Student ID:

(Last Name) (First Name) (Middle) (Date of Birth)

(Home Phone #) (Grade) (Teacher Name)

(Street Address) **NO P.O. BOXES** (City) (State) (Zip)

(Mother’s Name) (Father’s Name) (Sitter’s Name)

(Mother’s Cell #/Work #) (Father’s Cell #/Work #) (Sitter’s Cell #/Work #)

Description of physical pick up/drop off Location:

Emergency Information:

(Name of person to be called in case of an emergency) (Home #) (Cell Phone #) (Work #)

Please list any medical information you feel we should be aware of:

Alternate Pick up/Drop Off Location: If you need a pick up/or drop off other than address listed above, please complete below. Please consider

keeping one pick up/drop off point so as not to confuse your child.

Alt. Pick up Mon. – Tues. – Wed. – Thurs. – Fri. (Circle Days Needed) (Name) (Address) (Phone #/Cell #)

Alt. Drop off Mon. – Tues. – Wed. – Thurs. – Fri.

(Circle Days Needed) (Name) (Address) (Phone #/Cell #)

Parent’s Signature Date:

PARENTS REPORT ON CHILD

Child’s Name __________________________________________________________________________

Nickname ____________________________________ Birthdate _______________________________

Name you want your child to learn to write:

_____________________________________________________________________________________

What is your child’s favorite book:

What is your child’s favorite thing to play with at home?

_____________________________________________________________________________________

Write a few words that describe your child:

KINDERGARTEN READINESS CHECKLIST- PARENT RATING

Child’s Name:________________________________________ Date:________________________

Please complete the checklist below so that the school can have additional information on your child.

Please read each question below and check the column that best applies to your child.

CAN YOUR CHILD YES NO UNCERTAIN

Say, his/her own first and last name?

Address?

Telephone number?

Hold a book and turn pages one at a time?

Use scissors to cut paper

Draw and color pictures that are recognizable?

Listen and follow directions?

Concentrate quietly on an assigned task for at least ten minutes (i.e., cleaning up their room)?

Re-tell a story after listening to it?

Pay attention to a short story when it is read and answer simple questions about it?

Speak in sentences of more than four words?

Repeat 8 to 10 word sentences if you say it once, “The boy ran all the way home from the store?”

Usually make an effort to solve problems before seeking help from others?

Usually continue and activity without constant attention and encouragement?

Identify likenesses and differences in pictures, objects and forms?

Classify objects by categories, such as food or clothing?

Copy a circle, square, and triangle so that it is recognizable?

Compare objects according to size?

Tell how many objects, counting up to five?

Count by rote up to ten?

Match objects to pictures (i.e., toy truck to picture of a truck)?

dover union free school district 2368 route 22 registrar ......dover plains, ny 12522. welcome to...

Documents