Potosi Public School - 4 Year Old Kindergarten Pre-Registration
Emergency Health/History Family Form
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4K Student's Full Name *
Birth Date *
MM
/
DD
/
YYYY
Male/Female *
Race *
Birth County *
Birth City *
Birth State *
List all health issues that personnel need to be aware of: Diabetes, allergies, penicillin, bug bites, bees, migraines, etc. List current Medications and any concerns.
Mom's Name
Step-Father's Name
Mother's Address
Mother's Email Address
Mother's Home Phone (Do not list if you do not have a home phone)
Mother's Cell Phone
Mother's Work Phone
Mother's Employment
Mothers Work Hours
Father's Name
Step-Mother's Name
Father's Address
Father's Email Address
Father's Home Phone (Do not list if you do not have a home phone)
Father's Cell Phone
Father's Work Phone
Father's Work Hours
Child Lives With?  
Emergency Contact Information - Up to 6 People - Please enter Emergency Contacts Name along with their cell phone number and their relationship to the child.
English Language Learner  -- Check all that apply - Check if Answer is Yes - Leave Blank for No
All Schools Report data to the department of education using these new categories.  Enter or update the student data for your child.  
Clear selection
All Schools Report data to the department of education using these new categories.  Enter or update the student data for your child.   Racial Groups - check all that apply
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