Blackford County Schools

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Kindergarten Parent Questionnaire for incoming Kindergarten Students

My Child will attending Kindergarten at- *

Northside Elementary (Formerly Southside)

Montpelier

Child's Last Name *

Child's First Name *

Child's age? *

Child's Date of Birth *

YYYY

Address *

Primary Phone Number *

Mother's Last Name *

Mother's First Name *

Mother's Address *

Father's Last Name *

Father's First Name *

Father's Address *

If the student is not living with parent's, what is the Guardian's last Name?

If the student is not living with parent's, what is the Guardian's First Name?

With whom does the child Live ? *

Mother

Father

Both Parents

Guardian

Does The child have visitation with non-custodial parent?

Yes

Clear selection

Has custodial paperwork been submitted to the school?

Yes

Other:

Clear selection

Father/Stepfather place of employment

Mother/Stepmother place of employment

Names and ages of other children in the family

List of other member of the household

Did your child attend Head Start? *

Yes

Did your child attend Preschool? *

Yes

If your child attended preschool, where did they attend?

If your child attended Preschool who was the teacher?

Will your child be riding the bus? *

Yes

Maybe

To further assist in placement of your child, it may be helpful to speak with your child's preschool teacher. In order to do this, your signature is required to release this information. "I ___________________, give permission for a representative of Northside Elementary or Montpelier Elementary to speak with my child's Preschool/head Start Teacher."

Is your child currently under the care of a psychologist, psychiatrist or counselor? *

Yes

If your Child is under care of a psychologist, psychiatrist or counselor, are you willing to sign a release? *

Yes

Check any of the following behaviors that you have noticed in your child. *

Nightmares

Worries a lot

Easily frustrated

Afraid of being alone

Can sit still

Feels the need to be in control

Understands and obeys rules

Cries easily

Temper tantrums

Excessive shyness

never shows emotion

Follows spoken emotions

Follows a schedule or routine

Afraid of noises

Easily distracted

Explosive behavior

Has trouble falling asleep

Has toileting issues/accidents

Usually compliant with requests

Required

Would you like to discuss anything with our school counselor regarding your child? *

Yes

Is there anything special that you would like us to know about your child?

Submit

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This form was created inside of Blackford County Schools.

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