Incoming Kindergarten Readiness Assessment 
After completing this assessment, the school system will contact you with further information on how to proceed.
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Email *
Student's Last Name *
Student's First Name *
Student's Date of Birth *
MM
/
DD
/
YYYY
Street Address *
Parent Contact Phone Number *
Parent Contact Email address *
Form Completed By (please enter in name of guardian completing this form)
 *
Relationship to student *
Did your child attend a Pre-K program? *
If so, name and location of Pre-K Program
Has your child ever received birth to three services? *
Does your child have a current IEP or 504 Plan? *
Social Development *
YES
NOT YET
Has success in taking turns and sharing
Interacts appropriately with peers and adults
Asks for help when necessary
Follows through given instructions
Complies with rules, limits, and routines
Stays with an activity until completion (finishing a picture, building something)
Physical Development *
YES
NOT YET
Enjoys outdoor play such as running, jumping, and climbing
Puts together a puzzle
Holds a crayon or marker using a 3 finger grasp
Uses scissors to cut paper
Tries to tie his/her own shoes
Health and Safety *
YES
NOT YET
Has a set routine and schedule for preparing for bed, personal hygiene, and eating meals
Demonstrates healthy habits (uses a spoon to eat, covers nose to sneeze, washes hands)
Follows simple safety rules
Visits the doctor and dentist regularly
Eats a variety of food
Language *
YES
NOT YET
Speaks in sentences
Follows through when given multi-step directions
Uses simple conversational sentences
Talks about everyday experiences
Asks questions about how things work in the world around them
Expresses their ideas so that others can understand
Foundations for Learning *
YES
NOT YET
Arranges items in groups according to size, shape, or color
Groups items that are the same
Uses words like bigger, smaller, or heaviest to show comparison
Correctly counts four to ten objects
Has many books of their own and a special place to keep them
Recognizes their first name in print
Looks at books and pictures on their own
Tries to read in everyday situations (street signs, cereal boxes, etc.)
Tries to read along on favorite parts of a story or sentences that are repeated over and over again
Tries to write, scribble or draw
Asks a parent to write words or notes to people
Attempts to write their first name
Attempts to write their last name
What is your child's favorite book, and what types of books does your child enjoy? *
What activities and games does your child enjoy (outdoor sports, computer games, imaginative play, etc.) *
How would you characterize your child's behavior in a group, in a new setting, and at play with family or other children? (outgoing, reserved, cautious, etc.) *
What talents or hobbies does your child have? *
List any formal learning experiences your child has had.  Please include the name. *
What can you tell us about your child that will help us to ensure their success in kindergarten? *
Is there anything else that you believe is important for the district to know about your child? *
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