Dear Parents/Guardians, · Web viewLebanon Borough School District 6 Maple Street Lebanon, New Jersey 08833 Telephone: (908) 236-2448 Facsimile: (908) 236-7670 *Adapted from the sample

Lebanon Borough School District 6 Maple Street Lebanon, New Jersey 08833 Telephone: (908) 236-2448 Facsimile: (908) 236-7670

Dear Parents/Guardians,

Welcome to the Lebanon Borough School Family! We look forward to having your child join our Preschool Program for the 2016-2017 school year.

Please complete the following to ensure a smooth transition for your child’s move to Lebanon Borough School:

_____ Preschool Registration Information

_____ Preschool Checklist

_____ Preschool Health History

_____ Preschool Physical Exam Form

_____ Certificate of Immunization

_____ Authorization of Administration of Prescription Medication in School (if applicable)

_____ Proof of Residency (property tax bill, utility bill, deed, etc.)

_____Student’s original birth certificate with raised seal (will be copied and returned to you)

The above forms must be returned to the school office prior to your child first day at Lebanon Borough School. Please note that your child’s immunizations must be acceptable and up to date before your child can begin school. If you have any questions, please feel free to call the School Secretary or School Nurse at 908-236-2448, between 8:00 a.m. and 4:00 p.m.

Monthly fee for preschool is $200.00 a month due the first day of each month payable to: Lebanon Borough School.

____ Check Enclosed

Thank you.

LEBANON BOROUGH SCHOOLLebanon, New Jersey 08833

PRESCHOOL REGISTRATION INFORMATION

Today’s Date: Student’s Date of Entry into School:

Child’s Name: First Middle Last

Date of Birth:

Address:

Home Telephone Number: ( ) Is this number listed? Unlisted?

Cell Telephone: ( ) Pager: ( )

E-Mail: ____________________________________________________________

PARENT/ GUARDIAN INFORMATION

Parent/Guardian:

Date of Birth:

Occupation:

Employer’s Name:

Employer’s Address:

Employer’s Telephone Number: ( ) E-Mail:

Circle Highest Grade Completed: Elementary High School Vocational School College (number of years) College Degree Graduate Degree

PRESCHOOL REGISTRATION INFORMATIONPage Two

Parent/Guardian:

Date of Birth:

Occupation:

Employer’s Name:

Employer’s Address:

Employer’sTelephone Number: ( ) E-Mail:

Circle Highest Grade Completed: Elementary High School Vocational School College

(number of years) College Degree Graduate Degree

MARITAL STATUS OF PARENTS

Please check one: Married Divorced Separated Widowed

If separated or divorced, who has custody?

Does your child see the non-custodial parent? How often?

If there are other adults (i.e. guardian, relatives) that play an important role in your child’s life, please list below:

EMERGENCY INFORMATION

AlternateContact Person:

Pertinent Telephone Number(s):

Relationship:

PRESCHOOL REGISTRATION INFORMATIONPage Three

FAMILY RECORD

Child’s Status in Family: Oldest Middle Youngest Only

Multiple Birth

Other children in the family:

NAME BIRTHDATE AGE GRADE (Include last name if different.) (If applicable.)

Have any of your children experienced significant difficulties in school?

If so, which child?

Please explain nature of difficulty: _____________

________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Are there any recent changes in family life (i.e. birth, death, divorce, separation, recent move, etc.)? If so, please explain. __________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

STUDENT REGISTRATION INFORMATIONPage Four

Do you have any concerns about your child’s development?

________________________

What name/nickname do you wish your child to be called and to write?

What language(s) is spoken at home?

CHILD’S PRESCHOOL HISTORY

Did your child attend preschool?

If yes, please complete the following:

Name of preschool:

Address:

Telephone number:

May we call your child’s preschool if we need any additional information?

Number of years attended preschool:

Days per week:

Dates of attendance: From to

Lebanon Borough School District

6 Maple Street Lebanon, New Jersey 08833 Telephone: (908) 236-2448 Facsimile: (908) 236-7670

Dr. Robert SutterChief School Administrator

PRESCHOOL CHECKLIST

Child’s Name: _____________________________________________________________________

Person completing forms: ________________________________________________

Date: ___________________

Please complete the following information about your child.

GENERAL INFORMATION

Please respond with a yes or no, or comment. Can your child tell you…

His/her full name__________________________ How old he/she is ____________________

His/her phone number______________________ When his/her birthday is_______________

Name of mother___________________________ Name of father_______________________

Where he/she lives (write answer)_________________________________________________

Additional comments: _____________________________________________________________________________

______________________________________________________________________________

PRESCHOOL CHECKLIST Page Two

Print your child’s first name on the line and have your child copy it on this paper under your model.

______________________________________________________________________________

Have your child draw and color a picture with crayons or markers on the back of this page. Please explain what your child has drawn: ______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

PRESCHOOL CHECKLIST Page Three

1. Describe your child. Circle all that apply:

Friendly Chatty Serious Cooperative Fearful

Independent Stubborn Difficult to Handle Likes Own Way Persistent

Shy Quiet Extremely Quiet Sensitive Gives Up Easily

Overactive Bouncy Angers Easily Easily Upset Unruffled

Easy Going

Others/additional comments: ____________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

2. Does your child have a fear of strangers? ________________________________________

If so, please explain: ___________________________________________________________

______________________________________________________________________________

3. When changes (i.e., routines, plans) occur, does your child adjust easily? ____________

Does better when he/she knows in advance? ___________________________________

Does better without knowing? ______________________________________________

4. Can your child take care of his/her personal toilet needs? ____________________________

Control bathroom urgency? ________________________________________________

Is bed wetting still occurring? _______________________________________________

If so, please give more information: __________________________________________

5. Can your child work cooperatively with you? _____________________________________

6. Can your child adjust to being away from you for two to three hours without being upset?_______________

PRESCHOOL CHECKLIST Page Four

7. Does your child play regularly with children his/her age? __________________ Older children?

Younger children?

Please circle which group your child plays with the most: own age older younger

8. How does your child feel about going to school (i.e., eager, anxious)? Please explain.

LITERARY DEVELOPMENT

1. Does your child pretend to read?

2. How often is your child read to?

3. Can your child tell you a story from looking at the pictures?

4. Does your child pay attention when a story is read?

5. Can your child answer simple questions about a story that is read to him/her?

6. Does your child have a selection of books at home?

7. Do you and your child go to the public library?

8. Can your child read?

PRESCHOOL CHECKLIST Page Five

INTERESTS AND ACTIVITIES

1. What are your child’s favorite inside activity(s)?

________________________________________________________________________

2. What are your child’s favorite outside activity(s)?

________________________________________________________________________

3. Does your child have a special interest?

________________________________________________________________________

4. What are your child’s favorite television shows? 1) 2) 3)

5. Does your child participate in any organized group activities (i.e., sports, dance, art, clubs)? If so, please explain/list:

____________________________________________________________________

CONCLUSION

Is there anything else we should know about your child to help him/her have a successful Preschool year?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Home Language Survey(Parent/Guardian Language Questionnaire)

Name:__________________________________________________ Age: _____[first] [middle] [last]

Date of School Entrance_______________________

Person completing the survey: [ ] Mother [ ] Father [ ] Grandparent

[ ] Guardian [ ] Other _____________________

Directions: Check or write in the correct response for each of the following questions about your child.

1. What language did the child learn when he/she first began to talk?

English______ Other [specify]___________________________________

2. What language does the family speak at home most of the time?


3. What language does the parent [guardian] speak to the child most of the time?


4. What language does the child speak to his/her parent [guardian] most of the time?


5. What language does the child speak to her/her brothers and sisters most of the time?


6. What language does the child speak to his/her friends most of the time?


7. In which language do you wish to receive school communication?


Signature:_____________________________________ Date:_______________[person completing the survey]

*Adapted from the sample survey in A Manual for Community Representatives of the Title VI Steering Committee, published 9/76 by the Institute for Cultural Pluralism, Lau General Assistance Center, San Diego University, San Diego, CA 92182

Lebanon Borough School District 6 Maple Street Lebanon, New Jersey 08833 Telephone: (908) 236-2448 Facsimile: (908) 236-7670


PRESCHOOL HEALTH HISTORY

NAME:_____________________________ DOB:__________________SEX:______________PARENTS’NAMES:_______________________________PHONE:_________________________HEARING PROBLEMS-YES/NO IF YES, EXPLAIN:___________________________________FREQUENT or PROLONGED EARACHES-YES/NO # PER YEAR:_______________________USES HEARING AIDS: YES/NO HISTORY of EAR TUBES/WHEN:______________________SPEECH PROBLEMS: YES/NO IF YES, EXPLAIN:___________________________________VISION: GLASSES___________________ FREQUENT HEADACHES:_________________SITS CLOSE TO T.V. - YES / NO SQUINTS TO READ or WATCH T.V._______________ALLERGIES: Medication___________________ Food_______________Asthma_______________

Seasonal ____________________ Bee/Insect___________ Other_______________CURRENT MEDICATIONS:_________________________________________________________HISTORY of HIGH FEVERS- YES / NO WHEN:____________ SEIZURES - YES / NOCOMMUNICABLE DISEASES/ILLNESSES: PLEASE GIVE DATES_________________Measles _______________Strep Throat _______________Epilepsy_________________German Measles_______________Lymes _____________Pneumonia_________________Chicken Pox _______________Diabetes _______________Impetigo_________________Mumps _______________Heart Murmur_______________Eczema_________________Rheumatic Fever_______________Frequent Colds _________________ Other

HEAD INJURY: HOW OCCURRED___________________________ DATE:_________________TREATMENT_____________________________________________________________________FRACTURES: SITE________________________________________ DATE_________________HOSPITALIZATIONS/OPERATIONS with DATES:_______________________________________________________________________________________________________________________NUTRITION/FEEDING HABITS: Eats Well at Meals - Yes / No Frequent Snacks - Yes / NoFood Sensitivities - Yes / No Explain_______________________ Vegetarian Diet - Yes / No

List any factors during your pregnancy or in the early life of your child that you think have affected his/her development.__________________________________________________________________________________________________________________________________________________Please circle if appropriate: Prematurity Low Birth Weight Bed-wettingWas any evaluation done by the Child Study Team as a preschooler? Yes / No

PARENT SIGNATURE________________________________________ DATE_____________

Lebanon Borough School District

6 Maple Street Lebanon, New Jersey 08833 Telephone: (908) 236-2448 Facsimile: (908) 236-7670


PRESCHOOL PHYSICAL EXAM FORMTo be completed by your private physician

NAME:_____________________________ DOB:______________________ SEX:____________PARENTS’ NAMES:__________________________________________ PHONE:_____________ADDRESS:______________________________________________________________________HEIGHT:________________ WEIGHT:_____________________ BP:_______________________

ALLERGIES(Medications, Food, Bees, Pollen, etc.):________________________________________________________________________________________________________________________

EYES: VISUAL ACUITY: RIGHT________ LEFT____________ GLASSES________________ STRABISMUS__________________HEADACHES:______________________________

EARS: SWEEP CHECK: RIGHT______________________ LEFT_____________________RECURRENT OTITIS MEDIA____________________ EAR TUBES_______________

NOSE:_______________________ THYROID:__________________________________MOUTH / TEETH: (SORES, CAVITIES) ____________________________________________LYMPH NODES:___________________ HEART:_____________________________________ABDOMEN:_______________________ HERNIA:____________________________________LUNGS:__________________________ ASTHMA:___________________________________GENITOURINARY:________________ DESCENDED / UNDESCENDED TESTICLESORTHOPEDIC: ___________________ SCOLIOSIS:__________________________________SPEECH DIFFICULTY:__________________________________________________________

PAST SURGERY/ HOSPITALIZATIONS:_______________________________________________________________________________________________________________________________________________________________________________________________________MEDICATIONS: (STANDING or P.R.N.):_________________________________________________________________________________________________________________________ANY RESTRICTION ON PLAY OR PHYSICAL EDUCATION ACTIVITIES? __________________________________________________________________________________________RECOMMENDATIONS / REFERRALS:___________________________________________________________________________________________________________________________

PRINTED NAME OF PHYSICIAN:________________________________________________

SIGNATURE OF PHYSICIAN:_______________________________ DATE:______________

Documents

Dear Parents/Guardians, · Web viewLebanon Borough School District 6 Maple Street Lebanon, New Jersey 08833 Telephone: (908) 236-2448 Facsimile: (908) 236-7670 *Adapted from the sample