* for Office Use Only * Enrollment Visit Scheduled for ______ ______ Am Pm
* For Office Use Only * Enrollment Visit Scheduled For ______@ ______am pm
Enrollment Start Date:______
KILLINGLY PUBLICSCHOOLSFAMILYRESOURCECENTER
All information given will be kept confidential, so please answer all questions
to the best of your knowledge. Please circle or fill in the correct information
completely. Please print or type all information. Thank you for your cooperation.
CHILD INFORMATION
Family Phone # ( )______
Family E-Mail Address:______
Child’s Name:______Sex: M F
(First) (Middle) (Last)
Birth Place: ______Child’s Birthdate:____/____/____ Age:______
(if not U.S., list country of birth))
School Child Attends: KMS KCS Grade:______If “K”, Check Session: AM PM
Hours Needing To Attend: AM (6:30-8:30) PM (3:00-6:00)
½ DAY@ GOODYEAR ~Start Time:______Pick-up Time:______
Circle Days Needed: Mon Tues Wed Thurs Fri Total Days/Week ______
Child Lives With:___Both Parents ___Father ___Mother ___Other ______
Home Address: ______
Street City State Zip
Mailing Address:______
Street City State Zip
What language did the student learn to speak first? ______
What language is spoken by adults in student’s home? ______
What language does the student speak at home? ______
Ethnic group: White Black/African American Hispanic/Latino American Indian
Asian Native Hawaiian/Other Pacific Islander
Page 1 of 3
FAMILY UNIT INFORMATION
Parent/Legal Guardian
Name: ______D.O.B:______
(Last) (First) (Middle)
Relationship To Student:______Home Telephone:______
Address (if different from child): ______
Marital Status: Single Married Divorced Separated Widow Widower
Ethnic group: White Black Hispanic/Latino American Indian Asian
Parent/Legal Guardian Education (please circle the number of years completed):
Elementary/Secondary: K 1 2 3 4 5 6 7 8 9 10 11 12 College: 1 2 3 4 5+
Employment Information
Employer Name/Address:______
Position:______Work Hours:______
Work #: ( )______Ext:_____ Cell #:( )______
Parent/Legal Guardian’s Spouse:
Name: ______D.O.B:______
(Last) (First) (Middle) (Last) (First) (Middle)
Relationship To Student:______Home Telephone:______
Address (if different from child): ______
Marital Status: Single Married Divorced Separated Widow Widower
Ethnic group: White Black Hispanic/Latino American Indian Asian
Parent/Legal Guardian Education (please circle the number of years completed):
Elementary/Secondary: K 1 2 3 4 5 6 7 8 9 10 11 12 College: 1 2 3 4 5+
Employment Information
Employer Name/Address:______
Position:______Work Hours:______
Work #: ( )______Ext:_____ Cell #:( )______
PLEASE LIST OTHER HOUSEHOLD MEMBERS, RELATIONSHIP & AGE TO CHILD:
NAME (Last, First) RELATIONSHIP AGE
______
______
______
______
Page 2 of 3
EMERGENCY INFORMATION
Child’s Name:______ Date of Birth:______
Parent/Legal Guardian Name: ______
MEDICAL INFORMATION
Indicate phone number(s) where child’s parent/guardian may be reached during the day. ( )______
Child’s Dentist:______Phone #:______
Child’s Physician:______Phone #:______
Do you have health insurance coverage: Yes No
If yes, Health Insurance Carrier: ______Policy #:______
Is your health insurance coverage Public(ie: medicaid, HUSKY)or Private(ie: BC/BS, HMO)
As needed, I give permission to the FamilyResourceCenter staff to obtain emergency medical treatment
for my child with the understanding that my family will be notified as soon as possible.
OTHER REMARKS
Please indicate any limitations, restrictions, or concerns you have for your child (i.e., allergies, health problems, diet restrictions, fear of dogs, etc.).
______
Custody Alert/Special Family Circumstances :______
______
Release
In case I cannot pick up my child or in case of emergency, my child can be
released to the following people:
1. Name______Relationship To Child______
Home Telephone______Employer Telephone______
2. Name______Relationship To Child______
Home Telephone______Employer Telephone______
3. Name______Relationship To Child______
Home Telephone______Employer Telephone______
4. Name______Relationship To Child______
Home Telephone______Employer Telephone______
Parent/Legal Guardian’s Signature______Date______
Page 3 of 3
Killingly Public Schools ~ Family Resource Center
Health Information
Child’s Name:______
Doctor’s Name(s):______Phone#:______
Specify any health problems, allergies, etc:______
______
List any medications taken regularly:______
______
Other pertinent health information:______
Mother’s Name:______Work phone:______
Father’s Name:______Work phone:______
If we are unable to contact you in case of an illness or injury, please contact the following people:
Name:______Phone:______
Name:______Phone:______
Name:______Phone:______
In case of accident or serious injury and the program in unable to contact me directly, I/We authorize physician(s) ______to render such treatment as may be necessary for the health of my child. In the event that the physician(s)/guardian cannot be reached, the program is hereby authorized to take whatever action in necessary in their judgment, for the health of the child.
Signature:______Date:______
11/15/13
Killingly Public Schools ~ Family Resource Center
BASP PROGRAM TRANSPORTATION FORM
I______, give permission to the Killingly Before and
After School Program to transport my child, ______by van or
bus to and from any field trips planned by the program.
Signature:______Date:______
COMMUNITY FIELD TRIPS
I give my child______permission to attend and participate in any
activities conducted in the neighborhood of the Before and After School Program (KMS or KCS Site),
including but not limited to nature walks and visits to other building spaces. I understand that these
excursions will be supervised as are all the extended field trips.
Signature:______Date:______