Ohio County Schools & Audubon Area Head Start Preschool Registration Questionnaire
Parents: Please fill out this form for each child you would like to register for preschool. Someone from the preschool office will call you at the number you provide
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Student Demographic Data
First Name *
Child's first name
Last Name *
Child's last name
Child's Date of Birth *
MM
/
DD
/
YYYY
Street/PO Box Address *
City *
State *
Required
Zip Code *
Preschool *
Select one of the options if your child has previously attended preschool in Ohio County or another district. Choose "None" if your child has never attended preschool.
Required
School *
Choose the school that you would like for your child to attend Preschool. (There is no guarantee that their selection will result in placement in that school)
Parent Demographic Data
This information is for the primary parent. Other parent information will be collected at a later time.
Parent First Name *
Parent Last Name *
Parent Phone *
Parent Email
Optional
Areas of Concern
Diagnosis *
Does the child have a diagnosed medical condition? Please choose all that apply. If the child does not have a medical diagnosis, choose "Does not apply".
Required
IEP *
Does your child have an IEP relating to any of the following areas? Select, "Does not apply". An IEP is an Individual Education Program which would have been developed for your child to address an educational disability.
Services *
Does the child receive any therapy services?
Required
Development Checklist
Below you will check if you are concerned or not concerned for your child across multiple developmental areas.

Health: Do you have concerns with your child's overall health?
Cognitive: Do you have concerns with your child's ability to count, sort items, identify items.
Motor Skills: Do you have concerns about your child's movement (gross motor) or ability to use small objects like a crayon (fine motor).
Self-Care: Are your concerned about your child's ability to care for his/herself?
Social-Emotional: Do you have concerns related to your child's behavior or ability to understand his/her emotions.
Language Skills: Do you have concerns about your child's ability to understand and follow simple directions or ability to communicate using simple sentences.
Speech Sounds: Do you have concerns about your child's ability to produce age-appropriate sounds for letters and simple words.
Development *
Concerned
Not Concerned
Health
Cognitive
Motor Skills
Self-Care
Social-Emotional
Vision
Hearing
Language Skills
Speech Sounds
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