ENROLLMENT AND CUMULATIVE RECORD FORM FOR PRESCHOOL
CARROLL COMMUNITY SCHOOLS - CARROLL, IOWA 51401
For Office Use Only
Date of Entry______Grade_____Teacher______Locker _____State Student ID______
PS__FMP___Food Service____Transportation____Enrollment Date______Start Date______
______
Student’s Last Name First Name Middle
(Student’s Name should be written as it appears on the birth certificate)
Address ______
City ______Zip ______
Age ____ Grade ____
Phone Number ______
Birth Date ______Birth Place ______
Born outside U.S. (If so) Entry Date ______
Gender: Male Female
Resident of Carroll Comm. School. Dist. Yes No
If No, Resident District:______
Student lives with:
____ Father____ Father & Stepmother
____ Mother____ Mother & Stepfather
____ Guardian____ Both Parents
____ Relative____ Foster Parents
Student’s Native Language ______
Main Language spoken at home
______
List all children living at home:
Name______Age____
Native Lang. ______Ethnic Gp. ______Name______Age____
Native Lang. ______Ethnic Gp. ______Name ______Age____
Native Lang. ______Ethnic Gp. ______
(Please circle one)
Father / Step Father / Guardian ____________
Address ______Phone ______
Employer ______
Work # ______
Cell # ______
Email ______
Father’s Education: High School College
(Please circle one)
Mother / Step Mother / Guardian ____________
Address ______Phone ______
Employer ______
Work # ______
Cell # ______
Email ______
Mother’s Education: High School College
If divorced, specify: ___ Legal Custody
___ Joint legal custody
If joint legal custody please name parent below:
Name ______
Address ______
City ______State ___ Zip ______
Is there a current no contact order in place? Yes No
If yes, please provide the school with a copy of this order.
(See Other Side)
Emergency Contact Person: (Name & Phone - Not Parent)
1.______
2.______
Family Physician and Phone Number:
(to be called at expense of parent, if needed in emergency)
Family Dentist and Phone Number:
Special Services your child receives. Please check:
___ Speech ___ ESL/ELL ___ Sp. Education
___ Counseling ___G& T
___ At-Risk___504
___ Other: Please specify ______
If your child goes to a babysitter please list:
Name: ______
Address: ______
Phone: ______
Special information you want us to know about your son/daughter:
______
Is child currently enrolled in an Early Childhood Program? Yes No If yes, where______
Race/Ethnicity: Parents must complete BOTH questions.
- Is this student Hispanic/Latino? (Choose only one)
No, not Hispanic/Latino
Yes, Hispanic/Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
- What is the student’s race? (Choose one or more)
American Indian or Alaska Native (A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.)
Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam)
Black or African American (A person having origins in any of the black racial groups of Africa.)
Native Hawaiian or Other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.)
White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa)
This is a public school program. Carroll Community School and transportation scheduling will decide the preschool site placement. However in order to speed the site placement process we would ask you to check your site preference if you have one. We will try to accommodate your request.
Carroll Community School: ______
Kuemper Catholic School: ______
No Preference______
______
Parent/Guardian Signature