NEW STUDENT REGISTRATION Lewis-Palmer School District

146 Jefferson St., P.O. Box 40

Monument, CO 80132-0040

Phone: 719-488-4700

Fax: 719-785-4218

Preschool Registration

This packet contains documents and information for registering your

child for Preschool in Lewis-Palmer School District. When you turn in

the completed forms, please provide the following additional documents.

The registration office will not process the registration if any of the

required documents are missing.

• Verification of Address (One of the following)

o Warranty Deed

o Signed Contract with Name, Address, and Closing Date

o Settlement Statement from Closing

o Current El Paso County Tax Notice

o Construction Loan Statement

o Signed Contract with Builder

o Building Permit

o Current Rental or Lease Agreement

o Current Utility Bill

• Student’s Immunization Record

• Student’s Registered County Birth Certificate

• Custody Documentation or Power of Attorney (if the student does not

reside with the parent)

• Special Education IEP (if applicable)

• Photo Identification of Parent or Legal Guardian

* PLEASE NOTE: Preschool students must be 3 years old and toilet

trained. Please see the registration paperwork for information

concerning deposit requirements.

LEWIS-PALMER SCHOOL DISTRICT PRESCHOOL REGISTRATION FORM PLEASE PRINT CLEARLY Start Date:

Student’s Legal Name: (Last Name) (First Name) (Middle Name)

Grade Gender M F Place of Birth Birth Date

Ethnicity (choose one): Hispanic/Latino (a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race)

Not Hispanic/Latino

AND

Race (chose one or more):

American Indian or Alaskan Native (A person having origins in any of the original peoples of North, Central, or South America, and who

maintains cultural identification through tribal affiliation or community recognition)

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 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)

Male Head of Household: Employer: (Last Name) (First Name)

Phone Hm: Wk: Cell: Email:

Relationship to Student: Legal Guardian? Y N Resides With? Y N

Female Head of Household: Employer: (Last Name) (First Name)

Phone Hm: Wk: Cell: Email:

Relationship to Student: Legal Guardian? Y N Resides With? Y N

Street Address: (Number) (Street) (Apt #) (City) (State) (Zip)

Mailing Address: (If different) (Number) (Street) (Apt #) (City) (State) (Zip)

Names of other Children in the Household (please include preschool):

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

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

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

Emergency Contacts: The individuals below live locally, have authorization to pick up my student, and can be reached during school hours:

(Last Name) (First Name) (Relationship) (Phone)

(Last Name) (First Name) (Relationship) (Phone)

Has your child ever been enrolled in a Colorado School? Y N Has your child been enrolled in this district before? Y N

Has your child ever been assigned to any special programs? Y N If yes, please specify:

Would you like to be contacted by the Special Education Parent Liaison? Y N

Last school attended: (Name) (Address)

I verify the above information to be true

to the best of my knowledge.

(Parent/Guardian Signature) (Date)

FOR OFFICE USE

School Assignment: Contact/Phone: Transportation: 488-4711

Copies to: Parent/Guardian School SPED (IEP) Accounts Payable

(Original maintained at District Administration) Information entered by

DISTRICT #38 PRESCHOOL PROGRAMS SELECTION FORM FOR

2018-19 SCHOOL YEAR

Age of student by October 1, 2018 ____ years ____ months ___ Male ___ Female

Student’s Name Date of Birth

Parent’s Name Neighborhood School

Address Zip

Phone: Home Cell Work

School Program Preference:

PALMER LAKE EARLY CHILDHOOD CENTER

106 North Jefferson Street in Monument

(AM classes 8:30 – 11:30, PM class 12:30 – 3:30)

□ 4 days M-TH (PreK), indicate 1st & 2nd choice

AM _____ PM _____

□ 2 or 4 days (mornings), (3, 4 yrs)

M/W_____ T/TH _____ M-Th _____

□ 5 days preschool & childcare combo (3, 4, 5 yrs)

7:00 am - 5:00 pm

LEWIS PALMER ELEMENTARY 1315 Lake Woodmoor Drive

(AM class 8:55 – 11:55, PM class 12:40 – 3:40)

□ 4 days (afternoons) M-TH (PreK) FULL

□ 2 or 4 days (mornings), (3, 4 yrs)

M/W_____ T/TH _____ M-Th _____

PRAIRIE WINDS ELEMENTARY

no preschool at this site

BEAR CREEK ELEMENTARY

1330 Creekside Drive

(AM classes 8:55 – 11:55, PM classes 12:40 – 3:40)

□ 4 days M-TH (PreK), indicate 1st & 2nd choice

AM FULL PM _____

□ 2 or 4 days (mornings), (3, 4 yrs)

M/W FULL T/TH FULL M-Th FULL

□ 2 or 4 days (afternoons), (multiage 3, 4, 5 yrs)

M/W_____ T/TH _____ M-Th _____

□ 5 days preschool & childcare combo (3, 4, 5 yrs)

7:00 am - 5:00 pm FULL

KILMER ELEMENTARY

4285 Walker Road

(AM class 8:45 – 11:45, PM class 12:40 – 3:40)

□ 4 days (afternoons) M-TH, (PreK) FULL

□ 2 or 4 days (mornings), (3, 4 yrs)

M/W FULL T/TH FULL M-Th FULL

Program notes:

1. Students who turn four years old prior to Oct 1 are considered PreK and are eligible for the 4-day PreK

program. Younger students (3,4 yrs) may select either the 2-day or 4-day option.

2. Childcare services at Bear Creek Elementary School and Palmer Lake Early Childhood Center are available

only to students enrolled in a district preschool program.

3. Special Education services are provided during the preschool classroom sessions. Your student may be

assigned a preschool location and session based on service availability.

Parent’s Signature Date

DISTRICT #38 PRESCHOOL TUITION INFORMATION

2018-19 SCHOOL YEAR

Student Name: Date of Birth (mm/dd/yy):

Billing Address:

Tuition and fees are subject to Board of Education approval and may be adjusted. There are no

reductions for scheduled holidays, snow days, or other building emergencies. Any program

modifications must be requested and accomplished at Central Registration, and will only be

considered after all basic program enrollments (without modifications) are fulfilled.

2 half-day preschool option (M/W or T/Th) $165/month

4 half-day preschool option (M-Th) $280/month

5 day preschool & child care combination (up to 45 hrs/week) $725/month

Initial deposit requirements vary depending on when you register. The first $50 of your deposit

is non-refundable after June 1st. A deposit is only required for Colorado Preschool Project

students or Special Education preschool students if they are enrolled in childcare.

Registration period Initial Deposit Required by June 1

Feb – May prior to school year $50 Balance of one-month’s tuition

On or after June 1 One-month’s tuition N/A

Your deposit will be applied to the last month of school. You will not be billed for the month

of May unless there is additional payment owed.

Payment is due the first of the month. As a courtesy, you will be emailed a monthly invoice

beginning in August (or the first month your child attends school). Payment is due whether

you receive your invoice or not. If you don’t receive your invoice, please contact Karen

Alfultis at 719-785-4220. Payment methods include:

o Credit or debit card using your Infinite Campus Parent Portal Account

o Checks payable to LPSD #38 and mailed to:

o Credit card payments processed at the Administration Building incur an additional $3 fee

Late Payments: Your account may be assessed a $25 late payment fee if payment is not

received by the 10th

of the month. If your account is 30 or more days past due, your full-day

kindergarten student may be assigned to a half-day kindergarten class. In the case of

preschool, your child may be ineligible to attend until the past due account is satisfied.

Non-Sufficient Funds: If your check is returned for non-sufficient funds, your account may

incur a $10 NSF fee, in addition to a possible $25 late payment fee.

My signature below indicates I have read and understand the requirements listed above.

Parent/Guardian Name Signature Date

Office Use

School: Program: Start Date: Initials:

Deposit Information: Payment Amount: Method: Date:

LPSD Accounts Payable

PO Box 40

Monument, CO 80132

Lewis-Palmer School District #38 146 Jefferson Street, PO Box 40

Monument, CO 80132-0040

Administrative Office:

Phone (719) 488-4700 Fax (719) 785-4218

www.lewispalmer.org

RESIDENCY STATEMENT

A STUDENT RESIDENT FOR ADMISSION PURPOSES IN DISTRICT 38 SCHOOLS IS

DEFINED AS…A STUDENT WHO LIVES WITHIN THE BOUNDARIES OF DISTRICT 38

SCHOOLS. NOT INCLUDED IS…A BUSINESS ADDRESS, UNOCCUPIED HOUSE OR

APARTMENT ADDRESS, A VACANT LOT ADDRESS, POST OFFICE BOX, ETC.

PLEASE READ THE FOLLOWING STATEMENTS A AND B AND COMPLETE THE

STATEMENT THAT APPLIES TO YOUR RESIDENCY IN DISTRICT 38.

I, (print name) ________________________________________ (date)_________________

DO ATTEST, THAT MY CHILD IS, ACCORDING TO THE DEFINITION LISTED ABOVE,

NOW A RESIDENT LIVING WITHIN THE BOUNDARIES OF DISTRICT 38 SCHOOL.

OR

I, (print name) _________________________________________ (date)__________________

DO ATTEST, THAT MY CHILD, WILL BE, ACCORDING TO THE DEFINITION LISTED

ABOVE, A RESIDENT LIVING WITHIN THE BOUNDARIES OF DISTRICT 38 SCHOOLS.

SUBMISSION OF A PURCHASE/CONSTRUCTION CONTRACT OR RENTAL

CONTRACT WILL BE PROVIDED AS PROOF OF RESIDENCY BEFORE REGISTRATION

IS COMPLETED.

DATE ______________________

STUDENT NAME______________________________________________________

PARENT/GUARDIAN (signature)_________________________________________

ADDRESS____________________________________________________________

____________________________________________________________

PHONE (home)________________________________________________________

(work)_________________________________________________________

“In Pursuit of Excellence”

Lewis-Palmer School District #38 Home Language Survey

Required by the Office of Civil Rights Federal and state regulations require schools to determine the language(s) spoken and understood by each student. This information is requested so that schools may provide appropriate instruction.

TO BE FILLED OUT BY PARENT/GUARDIAN:

Student’s Name (Last) __________________________ (First) _________________________ (Middle) ______________ Date of Birth_____________ Parent/Guardian Name _______________________________________ What language(s) did your child use when he/she first began to speak? ___________________________________________________________________________________ What language(s) is spoken to the child by the following people? Mother__________ Father ___________ Siblings ___________ Others in the home ______________ What language(s) does your child speak to you at home/how often? ____________________________________________________________________________________ Do the adults in your home (parents, guardians, grandparents, others) speak to each other in a language

other than English all or part of the time? � � � � � � �

If yes, what language(s) are spoken/how often? ____________________________________________________________________________________ Child’s Country of Birth_______________________________________________________________ Date Child entered Colorado _______________ Date child entered USA ______________________

Can information from the school be sent home in English? � � � � � � �

IF A LANGUAGE OTHER THAN ENGLISH HAS BEEN INDICATED ABOVE, YOUR CHILD’S ENGLISH PROFICIENCY MAY BE TESTED. PLEASE CONTINUE: Does your child understand the conversations between adults in the home when they are speaking a

language other than English? � � � � � � �

Does your child participate in the conversation even though he/she might use English? � � � � �

What language(s) does your child read? _________________________________________________ What language(s) does your child write? _________________________________________________

Did your child ever attend school in another country? � � � � � � �

If yes, in which country, and what grades? _______________________________________________ What language(s) were used for instruction? _____________________________________________

Parent or Guardian Signature ___________________________________________________ Date ___________________

To be filled out by registration staff:

School _________ Grade _____ Start Date ________________ Copied to ELL Coordinator _________ Date Received By ELL Coordinator ________________________ Notes:

Original to be kept in student’s cum file Revised 3/12/10

Lewis Palmer District 38 Preschool

Authorization to Transport

Child’s Name: _____________________________________________________

Parent’s Names: ___________________________________________________

Home Phone: ________________________ Cell: ______________________

The following people are authorized to transport my child to/from preschool:

Name Relationship Phone Address

The following people may NOT transport my child to/from preschool:

Name Relationship Phone

The preschool staff will be notified of any changes.

____________________________ ___________________

Parent’s Signature Date

**I.D. will be required for unfamiliar people**

Lewis-Palmer School District 38 Preschool

Parent’s Signature Date

In each section, mark your choice. Then sign and return to school with your child.

Child’s Name:______________________________________________

____ I give permission for my child to be photographed and/or videotaped by Lewis-Palmer

School District 38 for educational, informational, and programming purposes including

the school web page and training media.

____ I do NOT give permission for my child to be photographed and/or videotaped by Lewis-

Palmer School District 38 for educational, informational, and programming purposes

including the school web page and training media.

____ I give permission for my telephone number/e-mail to be shared with other parents and/or

guardians in my child’s preschool class.

____ I do NOT give permission for my telephone number/e-mail to be shared with other

parents and/or guardians in my child’s preschool class.

____ I give permission for my child to be photographed for yearbook purposes.

____ I do NOT give permission for my child to be photographed for yearbook purposes.

____ I give permission for photos of my child to be viewed by families of children in my

child’s class.

____ I do NOT give permission for photos of my child to be viewed by families of children in

my child’s class.

____ I give permission for my child to accompany the preschool class on walks in, near, or

around the school building.

____ I do NOT give permission for my child to accompany the preschool class on walks in,

near, or around the school building.

____ I give permission for preschool staff to assist with applying sunscreen to bare surfaces

including the face, tops of ears, and bare shoulders, arms, legs and feet 15-30 minutes

before outdoor activities. I understand it is my responsibility to provide sunscreen with a

minimum SPF of 15.

____ I do NOT give permission for preschool staff to assist with applying sunscreen.

____ In the event of an early dismissal from school, my child will be picked up as usual.

____ In the event of any early dismissal from school, my child needs to: _________________

_______________________________________________________________________

I have read the handbook and understand the policies and procedures of the preschools of Lewis-

Palmer School District 38. I have also been made aware and authorize the school to allow my

child to view (on occasion), materials on video/television relating to the preschool’s weekly

teaching themes.

Emergency Information

Student’s Name:

Date of Birth:

Parent/Guardian #1

Name:__________________________________ Address: ________________________________ ________________________________________ Home Phone: ____________________________ Work Phone: ____________________________ Cell Phone: ____________________________ Relationship: ____________________________ Employer: ____________________________ Address: ____________________________ ____________________________________

Parent/Guardian #2 Name:__________________________________ Address: ________________________________ ________________________________________ Home Phone: ____________________________ Work Phone: ____________________________ Cell Phone: ____________________________ Relationship: ____________________________ Employer: ____________________________ Address: ____________________________ ____________________________________

Emergency Contact #1 (Other than the parent/guardian)

Name: __________________________________ Address: ________________________________ ________________________________________ Home Phone: ____________________________ Work Phone: ____________________________ Cell Phone: ____________________________ Relationship: ____________________________

Emergency Contact #2 (Other than the parent/guardian)

Name: __________________________________ Address: ________________________________ ________________________________________ Home Phone: ____________________________ Work Phone: ____________________________ Cell Phone: ____________________________ Relationship: ____________________________

Updated 12/2017

Lewis-Palmer School District 38 Health Information Form

(Must be completed annually)

Student’s Name:___________________________________________ Birthdate _______________ Grade _________

Parent Name(s): _________________________________________ Preferred Hospital __________________________

CIRCLE all CURRENT conditions listed below for your child

ADD/ADHD Blood Disorder Diabetes (pen/pump/CGM) Migraines

Allergies Bone/Joint Developmental Delays Seizures Type_____________________

Asthma Bowel/Bladder Head Injury/Concussion Stomach

Autism Depression Hearing Loss Other: _________________________

Please describe above circled conditions:

Please list any CURRENT medical diagnosis:

Is your child taking any routine medications? YES / NO

If YES, please list: Med Name/Dose/Time Taken _________________________________________________________________

Med Name/Dose/Time Taken _________________________________________________________________

Will your child take medication at school? YES / NO

Will your child self-carry any meds at school? (Prescription and/or OTC, 7-12th grades ONLY) YES / NO

(Please note: District 38 requires all students requiring medication to be given and/or self-carried at school, to have the Permission to

Administer Medication Form on file and renewed each school year signed by healthcare provider, parent and student if student is self-carrying.)

Does your child have any Life Threatening Allergies that school staff need to know about? YES / NO

If YES, please list allergy, reaction and date (month/year) of last reaction________________________________________________

Please circle one: I WILL or WILL NOT be providing school rescue medication such as epinephrine for severe allergy listed above.

I understand 911 will be called should an emergency arise.

Does your child have any dietary restrictions? YES / NO Please list: _________________________________________________

If YES, is restriction related to Food Allergy YES / NO Parent/Student preference YES / NO

Does your child wear glasses YES / NO Contacts YES / NO Have a known color vision defect YES / NO

Date of last vision exam (Month/Year) _____________ Eye Care Professional Name ______________________________________

Hospitalizations and/or surgeries (Month/Year/Description) ___________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

Student’s Physician Name/Address/Phone: _______________________________________________________________________

Student’s Dentist Name/Address Phone: _________________________________________________________________________

Medicaid? YES / NO Student’s Health Insurance Company: _______________________________________________________

I give permission for this information to be shared with adults in school setting who will be working with my child on a need-to-know

basis. It is the responsibility of the parent to notify the school nurse whenever there is any change in student’s health status or care and

ascertain any health information faxed/electronically sent to school by any outside sources have been received by the school

Form Completed by (Please Print): ________________________________________ Relationship to student: __________________

Parent/Guardian signature: ______________________________________________ Date: _________________________________

School Year ____________

HEALTH RECORD FOR LEWIS-PALMER SCHOOL DISTRICT #38

Children who enroll in preschool programs must submit a signed and dated statement of the child’s current health status which indicates the child’s abilities and/or limitations to participate in a regularly scheduled program of play in a group of young children. This report is to be filled out by a licensed physician or a licensed nurse practitioner who has seen the child in the last twelve months.

Child’s Name______________________________________________Sex_______Birth Date____________________

Address____________________________________________________________Phone_______________________

Past Illnesses – check those that the child has had and give approximate dates:

□ Chicken Pox

□ Rheumatic Fever

□ Mumps

□ Poliomyelitis

□ Rubella

□ Hay Fever

□ Epilepsy

□ Rubeola

□ Asthma

□ Diabetes

□ Whooping Cough

□ Other

This child is_____is not_____physically or emotionally able to participate in the day care program named above.

Comments:_______________________________________________________________________________________ ________________________________________________________________________________________________ Surgery/Accidents/Illnesses/Chronic or Handicapping Problems/Prosthetic Devices:______________________________ _________________________________________________________________________________________________ Describe any physical condition requiring special attention by center staff:______________________________________ _________________________________________________________________________________________________

Medication(s) prescribed:____________________________________________________________________________

Please submit physician’s order if medications are to be given at school.

Allergies that staff should be aware of__________________________________________________________________

Prescribed routine:_________________________________________________________________________________

If tuberculin test given: Date________________________________ Result___________________________________

If chest x-ray taken: Date________________________________ Result___________________________________

Vision__________________________________________Hearing___________________________________________

Please include any other pertinent information useful to service provider.

Please record immunizations and dates administered on the Colorado Department of Health Certificate of Immunization and attach to this form.

I hereby acknowledge there are no health concerns that would prohibit this child from attending preschool for the 2018-19 school year. ______________________________________________ ________________________ Signature of licensed physician or nurse practitioner Date Please print name and address:_____________________________________________________________________ ________________________________________________________________________________________________