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 Kindergarten 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:
_____ Kindergarten Registration Information
_____ Kindergarten Checklist
_____ Kindergarten Health History
_____ Kindergarten Physical Exam Form
_____ Certificate of Immunization
_____ Authorization for Administration of Prescription Medication in School (if applicable)
_____ Proof of Residency (property tax bill, utility bill, deed)
_____ 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.
Thank you.
Rev. 8/1/13
LEBANON BOROUGH SCHOOL
Lebanon, New Jersey 08833
KINDERGARTEN 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: ( )
E-Mail: ______
PARENT/ GUARDIAN INFORMATION
Parent/Guardian:
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
KINDERGARTEN REGISTRATION INFORMATION Page Two
Parent/Guardian:
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
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
Alternate
Contact Person:
Pertinent Telephone
Number(s):
Relationship:
KINDERGARTEN REGISTRATION INFORMATION Page 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 INFORMATION Page 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 Sutter
Chief School Administrator
KINDERGARTEN 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:
______
______
______
KINDERGARTEN 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: ______
______
______
______
KINDERGARTEN 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? ______
KINDERGARTEN 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?
KINDERGARTEN 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 kindergarten 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?
English______Other [specify]______
3. What language does the parent [guardian] speak to the child most of the time?
English______Other [specify]______
4. What language does the child speak to his/her parent [guardian] most of the time?
English______Other [specify]______
5. What language does the child speak to her/her brothers and sisters most of the time?
English______Other [specify]______
6. What language does the child speak to his/her friends most of the time?
English______Other [specify]______
7. In which language do you wish to receive school communication?
English______Other [specify]______
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
Dr. Robert Sutter
Chief School Administrator
KINDERGARTEN HEALTH HISTORY
(To be completed by parent/guardian)
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 / NO
COMMUNICABLE DISEASES/ SIGNIFICANT HEALTH CONCERNS (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 / No Food Sensitivities - Yes / No
Explain______
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-wetting
Was 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
Dr. Robert Sutter
Chief School Administrator
KINDERGARTEN PHYSICAL EXAM FORM
(To be completed by 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 TESTICLES ______
ORTHOPEDIC: ______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:______
LEBANON BOROUGH SCHOOL
AUTHORIZATION FOR ADMINISTRATION OF PRESCRIPTION MEDICATION IN SCHOOL
The following section is to be completed by the PARENT/GUARDIAN:
Student’s Name:______Date of Birth:______Grade:______
I request that my child be assisted in taking the medication described below at school by the School Nurse or other individuals authorized to administer medication to students in school pursuant to N.J.A.C:.6A:16-2.3. I understand the ultimate responsibility for administration of the medication is mine, and I am fully aware that the duties of the school nurse and others may require their presence at another location at the time that the medication is needed. I understand that the school district, agents and its employees shall incur no liability as a result of any condition or injury arising from the administration or lack of administration of the medication prescribed on this form. I indemnify and hold harmless the School District, its agents and employees against any claims arising out of administration or lack of administration of this medication.
Parent/Guardian Name:______Telephone:______
Signature: ______Date:______
RECOMMENDATIONS ARE EFFECTIVE FOR ONE SCHOOL YEAR ONLY AND MUST BE RENEWED ANNUALLY
The following section is to be completed by the PHYSICIAN:
Diagnosis for which medication is given: ______
Name of medication: ______
Dosage: ______
What time should the daily medication should be given? ______
If medicine is be given “WHEN NEEDED”, describe indications: ______
How soon can PRN medicine be repeated? ______
List significant side effects: ______
Any restrictions or limitations: ______
PLEASE CHECK THE APPROPRIATE OPTION
** RE: Class Trips and/or School Nurse is Unavailable (when a parent is unable to attend class trip or administer the
medication):
______YES, the prescribed dose can be withheld on the day of the class trip or if School Nurse is unavailable.
______YES, the time to be given can be adjusted with the parent/guardian.
______NO, this medication must be given to the child at the scheduled time.
I verify that this child is free from contagion and this medication is necessary for the student to fully participate in the school educational plan.
Physician’s Name:______Telephone:______
Address:______
Physician’s Signature:______Date:______
This form must be individually completed for all prescribed medications.
Medications are to be brought to school by the parent in the original container, labeled appropriately by the pharmacy.
All medications will be kept in a locked storage area.
It may not be possible to administer daily medication on half session days, early dismissal days or delayed opening days.
Parent/guardian will be notified if the daily medication could not be given to the student.
(rev. 2/2/12)