SULTAN SCHOOL DISTRICT Kindergarten Registration for 2021 …

SULTAN SCHOOL DISTRICT

Kindergarten Registration for 2021-2022

Students registering for the 2021-2022 school year – MUST BE FIVE YEARS OLD ON OR BEFORE AUGUST 31, 2021

Please bring the following information for registering a kindergarten student:

1. Age Verification – birth certificate, a religious, hospital, or

physician’s certificate showing date of birth; an entry in a family

bible; an adoption record; an affidavit from a parent; previously

verified school records; or any other documents permitted by law.

2. Immunization records – See enclosed WA State Department of Health

Vaccines Required for School Attendance chart.

Sultan School District #311 Registration Packet - Page 1

SULTAN SCHOOL DISTRICT #311

Today’s DateSCHOOL REGISTRATION

Student(legal)First Name Middle Name Last Name

Student(goes by)First Name Middle Name Last Name

Birth Date Age Sex Grade

If born outside of the United States, whatPlace of Birth date did student enter the U.S. schools? Date of Entry into USA

Student Lives with:Parent(s): YES NO, If NO, Legal Guardian: YES (Provide Court Documents) NO, (Must be Parent/Legal

Guardian with documentation)

Race/ Ethnic Category - Must be completed. See attached collection form.

Have you previously attended school in the Sultan School District? YES NO

Within the last 2 years, have you been enrolled in Special Ed (on an IEP) or in Resource Room classes. YES NO

Do you have brother/sister enrolled in other schools in the district? YES NO

Parent / Guardian Information (Who student lives with):

First Name Last Name Relationship Home Phone

Employer Work Phone Ext

Cell Phone Email Address


Employer Work Phone Ext

Cell Phone Email Address

Mailing Address City Zip Code

Physical Address City Zip Code

Complete this section if Student has a Parent / Guardian NOT living at the same address:



Mailing Address City Zip Code

Preferred Pronouns


SULTAN SCHOOL DISTRICT #311 EMERGENCY INFORMATION (To be updated annually)

Parent/Guardian Acknowledgment

I have instructed my child(ren) about this emergency procedure. I understand that in most emergency situations my child(ren) will be kept at school until regular dismissal time and will go home as usual.

Parent/Guardian Authorization for Emergency Procedure If the parent/guardian or authorized physician named on this registration form cannot be reached at the time of an emergency, and if immediate observation or treatment is deemed urgent in the judgement of the school authorities, I authorize and direct the school authorities to send the student (properly accompanied) to the hospital or doctor most easily accessible. I understand that I will assume full responsibility for the payment of any services rendered.

Doctor’s Name Doctor’s Phone Number

Parent/Legal Guardian Signature Date

Fund Balances Due to the cost of issuing refund checks, the district respectfully asks that families consider donating any balance remaining in your child’s accounts upon graduation or withdrawal to the Sultan School District. The amount will be retained and considered a donation to support general operations as long as the amount due does not exceed $5. Please indicate your approval by initialing here:______________

Student name (Legal):

First Middle Last

List up to three additional people we may contact in case of emergency if parents or guardians cannot be reached First Emergency Contact (if we can’t reach parent or guardian; contact must be local):

Name Relationship Phone Number Cell Home Work Second Emergency Contact (if we can’t reach a parent or first emergency contact; contact must be local):

Name Relationship Phone Number Cell Home Work Third Emergency Contact (if we can’t reach a parent, first, or second emergency contact; contact must be local):

Name Relationship Phone Number Cell Home Work

Ride bus as usual (animal) : Alternate drop-off location?:

Ride a different bus (animal): Riding home with (student):

Ride Boys & Girls Club bus as usual

Walk home as usual

Wait to be picked up (gym), within 30 minutes of school closure by parent or pre-approved emergency contact listed on this form.



Student Residency QuestionnaireFor distribution to all families/students annually

School:

Student(legal) First Name Middle Name Last Name

Birth Date Age Sex Grade

Part 1This form is intended to address requirements of the McKinney-Vento Act, Title X, Part C of the No Child Left Behind Act. Your answers to these questions will help staff with school enrollment and may enable the student to receive additional services.

1. Is your current residence a temporary living arrangement? Yes No

2. Is your living arrangement due to loss of housing or economic hardship? Yes No

3. Is your current residense inadequate for meeting physical and psychological needs? Yes No

If you answered YES to any of the above questions, please complete PART 2.If you answered NO to all of the questions, you may stop here.

Part 2 - Parents only answer if “Yes” to questions 1-3 in Part 1Where does the student stay at night? (Please check one box.)

In a motel/hotel

In a shelter

With more than one family in a house, mobile home, or apartment (doubled-up)

In a car, park, campsite, or location not usually used for sleeping accommodations (unsheltered)

Address________________________________________________________________________________ Phone______________ Street City Zip

Parent/Legal Guardian Name______________________________________________________

I declare under penalty of perjury under the laws of the State of Washington that the information provided here is true and correct.

Parent/Guardian Signature___________________________________________________________ Date________________ORUnaccompanied Youth Signature______________________________________________________ Date________________

For School Personnel Use Only

If student is missing enrollment records, please contact the student’s previous school for records.

Following records are still missing: (check all that apply)

Age verification Immunizations Medical records Prior academic records

School Personnel Signature__________________________________________________________ Date__________________

I hereby certify that the above named student qualifies for rights and services under the McKinney-Vento Act.

McKinney-Vento Liaison Signature____________________________________________________ Date____________



Thank you for providing the information needed on the Home Language Survey. Contact your school district if you have further questions about this form or about services available at your child’s school.Note to district: This form is available in multiple languages on http://www.k12.wa.us/MigrantBilingual/HomeLanguage.aspx. A response that includes a language other than English to question #2 OR question #3 triggers English language proficiency placement testing. Responses to questions #1 or #4 of a language other than English could prompt further conversation with the family to ensure that #2 and #3 were clearly understood. ”Formal education” in #7 does not include refugee camps or other unaccredited educational programs for children.

Forms and Translated Material from the Bilingual Education Office of the Office of Superintendent of Public Instruction are licensed under a Creative Commons Attribution 4.0 International License.

Student Name Grade Date

Office of Superintendent of Public Instruction (OSPI)Home Language Survey

The Home Language Survey is given to all students enrolling in Washington schools.

Parent / Guardian Name Parent / Guardian Signature

Eligibility for LanguageDevelopment SupportInformation about the student’s lan-guage helps us identify students who qualify for support to develop the language skills necessary for success in school. Testing may be necessary to determine if language supports are needed.

Right to Translation andInterpretation ServicesIndicate your language preference so we can provide an interpreter or translated documents, free of charge, when you need them.

Prior Education

Your responses about your child’s birth country and previous education:• Give us information about the

knowledge and skills your child is bringing to school.

• May enable the school district to receive additional federal funding to provide support to your child.

This form is not used to identifystudents’ immigration status.

All parents have the right to information about their child’seducation in a language they understand.

1. In what language(s) would your family prefer to communicate with the school?

__________________________________

2. What language did your child learn first? ______________________________________3. What language does your child use the most at home? ______________________________________4. What is the primary language used in the home, regardless of

the language spoken by your child? ______________________________________5. Has your child received English language development support

in a previous school? Yes_____ No_____ Don’t Know_____

6. In what country was your child born? ________________________________________

7. Has your child ever received formal education outside of the United States? (Kindergarten – 12th grade) ____Yes ____No

If yes: Number of months: _________________________

Language of instruction: ___________________________

8. When did your child first attend a school in the United States? (Kindergarten – 12th grade)

_______________________ Month Day Year



Ethnicity/Race Data Collection Form

Student Name Birth Date

QUESTION 1. Is your child of Hispanic or Latino origin? (Check all that apply.)

NOT HISPANIC/LATINO MEXICAN/ MEXICAN AMERICAN/ CHICANO CUBAN CENTRAL AMERICAN DOMINICAN SOUTH AMERICAN SPANIARD LATIN AMERICAN PUERTO RICAN OTHER HISPANIC/LATINO

QUESTION 2. What race(s) do you consider your child? (Check all that apply.)

AFRICAN AMERICAN/ BLACK ALASKA NATIVE CHEHALIS WHITE COLVILLE COWLITZ ASIAN INDIAN HOH CAMBODIAN JAMESTOWN CHINESE KALISPEL FILIPINO LOWER ELWHA HMONG LUMMI INDONESIAN MAKAH JAPANESE MUCKLESHOOT KOREAN NISQUALLY LAOTIAN NOOKSACK MALAYSIAN PORT GAMBLE KLALLAM PAKISTANI PUYALLUP SINGAPOREAN QUILEUTE TAIWANESE QUINAULT THAI SAMISH VIETNAMESE SAUK-SUIATTLE OTHER ASIAN SHOALWATER SKOKOMISH NATIVE HAWAIIAN SNOQUALMIE FIJIAN SPOKANE GUAMANIAN or CHAMORRO SQUAXIN ISLAND MARIANA ISLANDER STILLAGUAMISH MELANESIAN SUQUAMISH MICRONESIAN SWINOMISH SAMOAN TULALIP TONGAN YAKAMA OTHER PACIFIC ISLANDER OTHER WASHINGTON INDIAN OTHER AMERICAN INDIAN


SULTAN SCHOOL DISTRICT #311Student Health History

Student Name Grade Birth Date Todays Date

Please check any health concerns that your student has. If your student has no health concerns, check the space that says “No Health Concerns at this time” and return this form to the school as soon as possible.

No Health Concerns at this Time.

ALLERGIES SKELETAL/MUSCULAR Bee/Insect Allergy Spina Bifida Symptoms __________________________________ Scoliosis Medication Required?_________________________ Cerebral Palsy Food/Other Allergies ___________________________ Muscular Dystrophy Symptoms __________________________________ Other Skeletomuscular Problems ________________ Medications Required? ________________________ _________________________________________ RESPIRATORY NEUROLOGICAL Asthma/ Asthma Form Completed ________________ Grand Mal Seizures Symptoms __________________________________ Petit Mal Seizures Inhaler? ____________________________________ Febrile Seizures Triggers ____________________________________ Other Seizures _______________________________ Other _____________________________________ Tourette Syndrome ADD/ADHD (Circle) Medication _________________ CARDIOVASCULAR ________________________________ Other Neurological Problems ___________________ Heart Murmur Heart Disease DIGESTION/ELIMINATION High Blood Pressure Kidney Problems (or history of) Frequent Nosebleeds Bowel Control Problems Blood Disease Frequent Bladder Problems Other Ulcers Bedwetting DIABETES Other Related Concerns _______________________ Type 1 _______________________________________ Type 2 _______________________________________ BEHAVIORAL CONCERNS Medications __________________________________ Emotional Concerns Other Behavioral Concerns _____________________ HEARING PROBLEMS Hearing Loss OTHER HEALTH CONCERNS Ear Tubes Skin Problems (eczema, etc.) Frequent Ear Infections Other ______________________________________ Hearing Aids Other Hearing Problems ________________________ NEEDS/REQUESTS Student Takes Medication Daily VISION PROBLEMS Please Have School Nurse Contact Me Contacts/Glasses Student Needs Preferential Seating Color Blindness Reason _____________________________________ Vision Deficit Other _______________________________________

Please Complete and Return this Form as Soon as Possible.

Parent Signature ___________________________________________ Telephone Number ____________________________ I give permission for school nurses and registrars to access immunization records for my child on the WA State Dept. of Health Website. YES NOFOR INTERNAL USE ONLY: Medical Form Complete _____YES _____NO Reviewed by nurse ____(Initial)

Hepatitis B DTaP/Tdap

(Diphtheria, Tetanus,

Pertussis)

Polio

MMR (Measles, Mumps, Rubella)

Varicella

(Chickenpox)

Kindergarten

through 6th Grade 3 doses 5 doses* 4 doses* 2 doses

2 doses

OR

A health care provider

verified the child had

the disease

7th Grade through

12th Grade 3 doses

5 doses DTaP *

AND

1 dose Tdap

4 doses* 2 doses

2 doses

OR

A health care provider

verified the child had

the disease

* Vaccine Doses may be fewer than listed depending on your child’s situation.

Additional Information: Students must get vaccine doses at the correct timeframes to be in compliance with school requirements. Talk to your health care provider or school staff if you have questions about school immunization requirements.

There are important vaccines for children that are not required for school entry. Find information on these vaccines at www.immunize.org/cdc/schedules/.

Instructions: To see which vaccines are required for school, find your child’s grade in the first column. Look at the matching row across the page to find the amount of vaccines required for your child to enter school.

To request this document in another format, call 1-800-525-0127. Deaf or hard of hearing customers, please call 711 (Washington Relay) or email [email protected]. DOH 348-295 October 2020

Parents– Are Your Kids Ready for School? Required Immunizations for School Year 2021-2022

http://www.immunize.org/cdc/schedules/

▲Required for School ● Required Child Care/Preschool

Date MM/DD/YY

Date MM/DD/YY

Date MM/DD/YY

Date MM/DD/YY

Date MM/DD/YY

Date MM/DD/YY

Required Vaccines for School or Child Care Entry

●▲ DTaP (Diphtheria, Tetanus, Pertussis)

▲ Tdap (Tetanus, Diphtheria, Pertussis) (grade 7+)

●▲ DT or Td (Tetanus, Diphtheria)

●▲ Hepatitis B

● Hib (Haemophilus influenzae type b)

●▲ IPV (Polio) (any combination of IPV/OPV)

●▲ OPV (Polio)

●▲ MMR (Measles, Mumps, Rubella)

● PCV/PPSV (Pneumococcal)

●▲ Varicella (Chickenpox) History of disease verified by IIS

Recommended Vaccines (Not Required for School or Child Care Entry)

Flu (Influenza)

Hepatitis A

HPV (Human Papillomavirus)

MCV/MPSV (Meningococcal Disease types A, C, W, Y)

MenB (Meningococcal Disease type B)

Rotavirus

Certificate of Immunization Status (CIS) Reviewed by: Date:

Signed COE on File? Yes No

Please print. See back for instructions on how to fill out this form or get it printed from the Washington State Immunization Information System.

Child’s Last Name: First Name: Middle Initial: Birthdate (MM/DD/YYYY):

I give permission to my child’s school/child care to add immunization information into the Immunization Information System to help the school maintain my child’s record.

Conditional Status Only: I acknowledge that my child is entering school/child care in conditional status. For my child to remain in school, I must provide required documentation of immunization by established deadlines. See back for guidance on conditional status.

Parent/Guardian Signature Date Parent/Guardian Signature Required if Starting in Conditional Status Date

Documentation of Disease Immunity (Health care provider use only)

If the child named in this CIS has a history of varicella (chickenpox) disease or can show immunity by blood test (titer), it must be veri-fied by a health care provider. I certify that the child named on this CIS has: A verified history of varicella (chickenpox) disease. Laboratory evidence of immunity (titer) to disease(s) marked below.

Diphtheria Hepatitis A Hepatitis B

Hib Measles Mumps

Rubella Tetanus Varicella

Polio (all 3 serotypes must show immunity)

►

Licensed Health Care Provider Signature Date

►

Printed Name

I certify that the information provided on this form is correct and verifiable.

Health Care Provider or School Official Name: ______________________________ Signature: ______________________ Date:___________ If verified by school or child care staff the medical immunization records must be attached to this document.

X X

Reference guide for vaccine trade names in alphabetical order For updated list, visit https://www.cdc.gov/vaccines/terms/usvaccines.html

Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine

ActHIB Hib Fluarix Flu Havrix Hep A Menveo Meningococcal Rotarix Rotavirus (RV1)

Adacel Tdap Flucelvax Flu Hiberix Hib Pediarix DTaP + Hep B + IPV RotaTeq Rotavirus (PV5)

Afluria Flu FluLaval Flu HibTITER Hib PedvaxHIB Hib Tenivac Td

Bexsero MenB FluMist Flu Ipol IPV Pentacel DTaP + Hib +IPV Trumenba MenB

Boostrix Tdap Fluvirin Flu Infanrix DTaP Pneumovax PPSV Twinrix Hep A + Hep B

Cervarix 2vHPV Fluzone Flu Kinrix DTaP + IPV Prevnar PCV Vaqta Hep A

Daptacel DTaP Gardasil 4vHPV Menactra MCV or MCV4 ProQuad MMR + Varicella Varivax Varicella

Engerix-B Hep B Gardasil 9 9vHPV Menomune MPSV4 Recombivax HB Hep B

If you have a disability and need this document in another format, please call 1-800-525-0127 (TDD/TTY call 711). DOH 348-013 November 2019

Instructions for completing the Certificate of Immunization Status (CIS): Print the from the Immunization Information System (IIS) or fill it in by hand.

To print with the immunization information filled in: Ask if your health care provider’s office enters immunizations into the WA Immunization Information System (Washington’s statewide registry). If they do, ask them to print the CIS from the IIS and your child’s immunization information will fill in automatically. You can also print a CIS at home by signing up and logging into MyIR at https://wa.myir.net. If your provider doesn’t use the IIS, email or call the Department of Health to get a copy of your child’s CIS: [email protected] or 1-866-397-0337. To fill out the form by hand: 1. Print your child’s name and birthdate, and sign your name where indicated on page one. 2. Write the date of each vaccine dose received in the date columns (as MM/DD/YY). If your child receives a combination vaccine (one shot that protects against several diseases), use the Reference Guides below to record each vaccine correctly. For example, record Pediatix under Diphtheria, Tetanus, Pertussis as DTaP, Hepatitis B as Hep B, and Polio as IPV. 3. If your child had chickenpox (varicella) disease and not the vaccine, a health care provider must verify chickenpox disease to meet school requirements. If your health care provider can verify that your child had chickenpox, ask your provider to check the box in the Documentation of Disease Immunity section and sign the form. If school staff access the IIS and see verification that your child had chickenpox, they will check the box under Varicella in the vaccines section. 4. If your child can show positive immunity by blood test (titer), have your health care provider check the boxes for the appropriate disease in the Documentation of Disease Immunity section, and sign and date the form. You must provide lab reports with this CIS. 5. Provide proof of medically verified records, following the guidelines below. Acceptable Medical Records All vaccination records must be medically verified. Examples include:

A Certificate of Immunization Status (CIS) form printed with the vaccination dates from the Washington State Immunization Information System (IIS), MyIR, or another state’s IIS.

A completed hardcopy CIS with a health care provider validation signature.

A completed hardcopy CIS with attached vaccination records printed from a health care provider’s electronic health record with a health care provider signature or stamp. The school administrator, nurse, or designee must verify the dates on the CIS have been accurately transcribed and provide a signature on the form.

Conditional Status Children can enter and stay in school or child care in conditional status if they are catching up on required vaccines for school or child care entry. (Vaccine series doses are spread out among minimum intervals, so some children may have to wait a period of time before finishing their vaccinations. This means they may enter school while waiting for their next required vaccine dose). To enter school or child care in conditional status, a child must have all the vaccine doses they are eligible to receive before starting school or child care. Students in conditional status may remain in school while waiting for the minimum valid date of the next vaccine dose plus another 30 days time to turn in documentation of vaccination. If a student is catching up on multiple vaccines, conditional status continues in a similar manner until all of the required vaccines are complete. If the 30-day conditional period expires and documentation has not been given to the school or child care, then the student must be excluded from further attendance, per RCW 28A.210.120. Valid documentation includes evidence of immunity to the disease in question, medical records showing vaccination, or a completed certificate of exemption (COE) form.



Release of Student Information & Photo Release “Opt Out Form”

This form should be filled out ANNUALLY and kept on file with the child’s school ONLY IF PARENTS CHOOSE AN OPT-OUT OPTION. If you DO NOT want your child’s photo or name published, please complete the form below and return to your child’s school where it will be forwarded to the District Office.

The district publishes student names and photographs when reporting on student activities to recognize student achievement and for public information purposes. The Family Educational Rights and Privacy Act (FERPA} is a federal law that protects the privacy of student education records while FERPA also allows school districts to release “Directory Information” without specific consent from parents. Parents and eligible students have a right to opt out of the inclusion of information about the student such as directory information, photo/image, and student work. If you wish to opt out, you must check the box (es} below and return this form no later than September 30 or ten days following the student’s enrollment in the district, whichever is later. This election is good for the remainder of the school year.

If no form is on file it will be assumed that permission for release of photos, names and or directory information has been granted.

NOTE• Keep in mind if you choose NOT to have your child’s name and/or photo published, and your child is an

award winner, honor roll member, or other honoree that is celebrated in print, we will NOT be able to publish a name or picture, depending on your request.

• Your child may be photographed, though not identified, if the photograph is of a large group situation such as an assembly or team activity.

PLEASE DO NOT include my student’s information in directory information* that may be released without my consent including, but not limited to: Yearbooks, Newsletters, Brochures, Awards, District Calendar.

PLEASE DO NOT release directory information to military recruiters (HIGH SCHOOL ONLY)*

PLEASE DO NOT publish my student’s photo/image and student work*

Student Name: ____________________________________________ Grade: _________________

School: _________________________________________ School Year: ______________________

Student Birth Date: ____________ Parent Name: _______________________________________

Parent / Guardian Signature / Students 18 or Older Date

*Complete FERPA information is provided on the back of this form, or at the district’s websiteat:

www.sultanschools.org



About FERPA The Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99) is a Federal law that protects the privacy of student education records. The law applies to all schools that receive funds under an applicable program of the U.S. Department of Education. FERPA gives parents certain rights with respect to their children’s education records. These rights transfer to the student when he or she reaches the age of 18 or attends a school beyond the high school level. Students to whom the rights have transferred are ‘eligible students.’

Parents or eligible students have the right to inspect and review the student’s education records maintained by the school. Schools are not required to provide copies of records unless, for reasons such as great distance, it is impossible for parents or eligible students to review the records. Schools may charge a fee for copies.

Parents or eligible students have the right to request that a school correct records which they believe to be inaccurate or misleading. If the school decides not to amend the record, the parent or eligible student then has the right to a formal hearing. After the hearing, if the school still decides not to amend the record, the parent or eligible student has the right to place a statement with the record setting forth his or her view about the contested information.

Generally, schools must have written permission from the parent or eligible student in order to release any information from a student’s education record. However, FERPA allows schools to disclose those records, without consent, to the following parties or under the following conditions (34 CFR § 99.31):

• School officials with legitimate educational interest • Other schools to which a student is transferring • Specified officials for audit or evaluation purposes • Appropriate parties in connection with financial aid to a student • Organizations conducting certain studies for or on behalf of the school

• Accrediting organizations • To comply with a judicial order or lawfully issued

subpoena • Appropriate officials in cases of health and safety

emergencies • State and local authorities, within a juvenile justice

system, pursuant to specific State law.Student Directory Information: Public Disclosure of Student Directory Information (For ALL Students Grades PreK-12) In accordance with federal and state laws, the Sultan School District may release student directory information for various purposes. Student directory information is defined by the District’s Board of Directors, and may include:

Release of Directory Information to the ARMED FORCES :( High School Students Only) The No Child Left Behind Act of 2001 (NCLB) and the National Defense Authorization Act for Fiscal Year 2002 both require high schools to provide military recruiters with access to directory-type information on secondary school students. Upon request, and after notifying parents, schools must release to military recruiters the name, address, and telephone numbers of high school juniors and seniors, unless the parent or eligible student has opted out of the release of this information to military recruiters. If you wish to opt out, you must check the box and return this form no later than September 30 or ten days following the student’s enrollment In the District, whichever is later. This election is good for the remainder of the current school year.

Publishing of Pictures, Videos & Student Art/Work in Schools Sultan School District likes to celebrate the achievements of our students and staff. Throughout the year district staff may take photo-graphs of students and school activities. These photographs may appear in various district materials, including the district’s website (www.su1tan.k12.wa.us), newsletters, yearbooks, brochures, district calendar, etc. We, at times, may also publicize student work.

• Student name, address, and telephone number • Date and place of birth • Major field of study • Participation in officially recognized activities and sports • Weight and height of members of athletic teams • Dates of attendance

• School yearbooks (including photos) • Team rosters and class lists • Graduation, theater, athletic, and musfc programs • Video performances, school activities, and athletic events

• Honors, awards & degrees received • School & grade level • Previous educational agencies or institutions attended

by the student • Photographs, videos and other similar information

• Articles about school activities and athletic events • School honor roll, scholarships and other awards • Releases to media

Public disclosure of student directory information may occur in:



Under a new provision in the Federal Education Law, Senate Bill 369, all schools are required to formally track mil-itary families. If you are the parent or guardian of a student and are a member active in the US military forces listed below, please check yes, otherwise check no. Return signed form with your student or to your student’s school office by September 15.

U.S. Military Service

• Is one parent or guardian a current member of active duty US Armed Forces?

Yes

No

• Is one parent or guardian a current member of the Reserves of the US Armed Forces?

Yes

No

• Is one parent or guardian a current member of the Washington National Guard?

Yes

No

• Is a second parent or guardian a current member of the active duty US Armed Forces, Reserves of the

US Armed Forces or Washington National Guard?

Yes, a second parent

No

_______________________________________________ ____________________________________Student’s Full Name and Teacher

___________________________________________________Parents Signature



Sultan School DistrictKindergarten Child Survey

Student’s name

Has your child attended a formal preschool? ___ yes ___ no

Name of preschool: ___________________________________________

Can your child identify letters? Does your child know letter sounds? all or most letters all or most letter sounds some letters some letter sounds few letters few letter sounds

How would you classify your child’s reading ability: pre-reader (knows some environment print, such as stop signs, on, off but not “book print”) emerging reader (some “book print”, some letter/sound decoding) reader (knows fair amount of words is able to decode or “sound out” many words)

Does your child know how to write his/her first & last name? yes no

Does your child write any numbers? How high of number concepts does your child have? yes up to 10 no up to 20 over 20 consistently to 100

At what age did your child begin to speak? first words two or three words together sentences

Does your child stutter? yes no

Does your child have difficulty expressing ideas and concepts? yes no

Do you suspect any vision problems? yes no

Does your child wear glasses? yes no

Do you feel your child has adequate large muscle coordination? yes no



Sultan School DistrictKindergarten Child Survey

continued

Does your child:

catch a ball thrown to him/her yes no

enjoy physical activities yes no

lose balance, trip and fall more often than normal yes no

have difficulty running yes no

have regular playmates the same age yes no

have difficulty getting along with other children yes no

prefer to play with other children instead of alone yes no

become easily frustrated yes no

cry often yes no

have a bad temper yes no

enjoy cooperating with others yes no

become frequently irritated or moody yes no

become upset by changes in routine yes no

have difficulty dealing with family stress(illness, death or separation) yes no

demand much individual adult attention yes no

accept discipline and limits yes no

sit and listen to a story for 10 minutes yes no