Garden Plain Elementary School

Please Fill Out The Preschool Student Data Form Below

Child's First Name

Child's Middle Name

Child's Last Name

Child's Preferred Name

Gender

Reaquired field: Female

Reaquired field: Male

Date of Birth:

Age Group:

Reaquired field: 3 Year Old

Reaquired field: 4 Year Old

Hispanic/Latino?

Reaquired field: Yes

Reaquired field: No

Race (check all that apply)

Reaquired field: American Indian or Alaska Native

Reaquired field: Asian

Reaquired field: Black or African American

Reaquired field: Native Hawaiian/Pac. Islander

Reaquired field: White

Please list older siblings in K-8

Please list the last school your child attended

Does this student have an IEP?

Reaquired field: Yes

Reaquired field: No

Is your child right or left handed?

Reaquired field: Right

Reaquired field: Left

Child resides with:

Reaquired field: Both Parents

Reaquired field: Mother

Reaquired field: Father

Reaquired field: Other

Mother's First and Last Name

Reaquired field: Mother's Address

Address

City

State / Province / Region

Zipcode Min: 1 Max: 5

Country

Home Phone if available

Mother's Cell Phone:

Mother's Email:

Mother's Occupation

Mother's Work Phone:

Father's First and Last Name

Father's Address if different than Mother's address:

Address

City

State / Province / Region

Zipcode Min: 1 Max: 5

Country

Father's Cell Phone:

Father's Email Address:

Father's Occupation

Father's Work Phone:

Medical Information

Physician Name

Physician Phone Number

Preferred Hospital

Does your child have any FOOD allergies:

Does your child have any OTHER allergies:

List any medications taken routinely or intermittently:

Are there any medical problems we should be aware of:

Medical Notes

Are there any speech problems or concerns:

Can your child be relied upon to indicate his/her bathroom wishes?

Parent Permissions:

Student has permission to attend all field trips throughout the year. I will be notified of all events and have the right to deny participation.

Reaquired field: Yes

Reaquired field: No

Student's name and/or picture may appear in the Elementary Owl.

Reaquired field: Yes

Reaquired field: No

Student's name and/or picture may appear in the Garden Plain Elementary Yearbook

Reaquired field: Yes

Reaquired field: No

Student's name and/or picture may be shared with the media. some examples include, but not limited to: Times-Sentinel, Wichita Eagle, television/radio news programs, etc...

Reaquired field: Yes

Reaquired field: No

Student's picture may be used on social media (facebook, twitter,instagram,school website) when posting student activities. No student will be named individually.

Reaquired field: Yes

Reaquired field: No

Student's name and family information may be published in the Garden Plain Preschool student directory.

Reaquired field: Yes

Reaquired field: No

I acknowledge I have access to the School Handbook on the GPE website.

Reaquired field: Yes

Reaquired field: No

Emergency Contact #1 First & Last Name (if parents are unavailable):

Emergency Contact #1 Phone Number:

Emergency Contact #1 Relationship

Grandmother

Grandfather

Sibling

Daycare

Other Relative

Emergency Contact #2 First & Last Name (if parents are unavailable):

Emergency Contact #2 Phone Number:

Emergency Contact #2 Relationship

Grandmother

Grandfather

Sibling

Daycare

Other Relative

Persons authorized to pick up your child:

Who MAY NOT pick up your child:

Email a copy to

optional

Required Fields

Garden Plain Elementary

Preschool Student Data Form

GARDEN PLAIN PRESCHOOL

2024-25 Preschool Student Data Form