Blackford County Schools
Kindergarten Parent Questionnaire for incoming Kindergarten Students
My Child will attending Kindergarten at- *
Child's Last Name *
Child's First Name *
Child's age? *
Child's Date of Birth *
MM
/
DD
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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 ? *
Does The child have visitation with non-custodial parent?
Clear selection
Has custodial paperwork been submitted to the school?
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? *
Did your child attend Preschool? *
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? *
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? *
If your Child is under care of a psychologist, psychiatrist or counselor, are you willing to sign a release? *
Check any of the following behaviors that you have noticed in your child. *
Required
Would you like to discuss anything with our school counselor regarding your child? *
Is there anything special that you would like us to know about your child?
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This form was created inside of Blackford County Schools.