<p>Lebanon Borough School District 6 Maple Street Lebanon, New Jersey 08833 </p><p>Telephone: (908) 236-2448 Facsimile: (908) 236-7670</p><p>Dr. Robert Sutter Chief School Administrator</p><p>Dear Parents/Guardians,</p><p>Welcome to the Lebanon Borough School Family! We look forward to having your child join our Preschool Program for the 2016-2017 school year.</p><p>Please complete the following to ensure a smooth transition for your child’s move to Lebanon Borough School:</p><p>_____ Preschool Registration Information</p><p>_____ Preschool Checklist</p><p>_____ Preschool Health History</p><p>_____ Preschool Physical Exam Form</p><p>_____ Certificate of Immunization</p><p>_____ Authorization of Administration of Prescription Medication in School (if applicable)</p><p>_____ Proof of Residency (property tax bill, utility bill, deed, etc.)</p><p>_____Student’s original birth certificate with raised seal (will be copied and returned to you) </p><p>The above forms must be returned to the school office prior to your child first day at Lebanon Borough School. Please note that your child’s immunizations must be acceptable and up to date before your child can begin school. If you have any questions, please feel free to call the School Secretary or School Nurse at 908-236-2448, between 8:00 a.m. and 4:00 p.m.</p><p>Monthly fee for preschool is $200.00 a month due the first day of each month payable to: Lebanon Borough School. </p><p>____ Check Enclosed </p><p>Thank you. LEBANON BOROUGH SCHOOL Lebanon, New Jersey 08833</p><p>PRESCHOOL REGISTRATION INFORMATION</p><p>Today’s Date: Student’s Date of Entry into School: </p><p>Child’s Name: First Middle Last</p><p>Date of Birth: </p><p>Address: </p><p>Home Telephone Number: ( ) Is this number listed? Unlisted? </p><p>Cell Telephone: ( ) Pager: ( ) </p><p>E-Mail: ______</p><p>PARENT/ GUARDIAN INFORMATION</p><p>Parent/Guardian: </p><p>Date of Birth: </p><p>Occupation: </p><p>Employer’s Name: </p><p>Employer’s Address: </p><p>Employer’s Telephone Number: ( ) E-Mail: </p><p>Circle Highest Grade Completed: Elementary High School Vocational School College (number of years) College Degree Graduate Degree PRESCHOOL REGISTRATION INFORMATION Page Two</p><p>Parent/Guardian: </p><p>Date of Birth: </p><p>Occupation: </p><p>Employer’s Name: </p><p>Employer’s Address: </p><p>Employer’s Telephone Number: ( ) E-Mail: </p><p>Circle Highest Grade Completed: Elementary High School Vocational School College (number of years) College Degree Graduate Degree</p><p>MARITAL STATUS OF PARENTS</p><p>Please check one: Married Divorced Separated Widowed </p><p>If separated or divorced, who has custody? </p><p>Does your child see the non-custodial parent? How often? </p><p>If there are other adults (i.e. guardian, relatives) that play an important role in your child’s life, please list below:</p><p>EMERGENCY INFORMATION</p><p>Alternate Contact Person: </p><p>Pertinent Telephone Number(s): </p><p>Relationship: PRESCHOOL REGISTRATION INFORMATION Page Three</p><p>FAMILY RECORD</p><p>Child’s Status in Family: Oldest Middle Youngest Only Multiple Birth </p><p>Other children in the family:</p><p>NAME BIRTHDATE AGE GRADE (Include last name if different.) (If applicable.)</p><p>Have any of your children experienced significant difficulties in school? </p><p>If so, which child? </p><p>Please explain nature of difficulty: ______</p><p>______</p><p>______</p><p>______</p><p>Are there any recent changes in family life (i.e. birth, death, divorce, separation, recent move, etc.)? If so, please explain. ______</p><p>______</p><p>______</p><p>______STUDENT REGISTRATION INFORMATION Page Four</p><p>Do you have any concerns about your child’s development? </p><p>______</p><p>What name/nickname do you wish your child to be called and to write?</p><p>What language(s) is spoken at home? </p><p>CHILD’S PRESCHOOL HISTORY</p><p>Did your child attend preschool? </p><p>If yes, please complete the following:</p><p>Name of preschool: </p><p>Address: </p><p>Telephone number: </p><p>May we call your child’s preschool if we need any additional information? </p><p>Number of years attended preschool: </p><p>Days per week: </p><p>Dates of attendance: From to Lebanon Borough School District </p><p>6 Maple Street Lebanon, New Jersey 08833 </p><p>Telephone: (908) 236-2448 Facsimile: (908) 236-7670</p><p>Dr. Robert Sutter Chief School Administrator</p><p>PRESCHOOL CHECKLIST</p><p>Child’s Name: ______</p><p>Person completing forms: ______</p><p>Date: ______</p><p>Please complete the following information about your child.</p><p>GENERAL INFORMATION</p><p>Please respond with a yes or no, or comment. Can your child tell you…</p><p>His/her full name______How old he/she is ______</p><p>His/her phone number______When his/her birthday is______</p><p>Name of mother______Name of father______</p><p>Where he/she lives (write answer)______</p><p>Additional comments: ______</p><p>______PRESCHOOL CHECKLIST Page Two</p><p>Print your child’s first name on the line and have your child copy it on this paper under your model.</p><p>______</p><p>Have your child draw and color a picture with crayons or markers on the back of this page. Please explain what your child has drawn: ______</p><p>______</p><p>______</p><p>______PRESCHOOL CHECKLIST Page Three</p><p>1. Describe your child. Circle all that apply:</p><p>Friendly Chatty Serious Cooperative Fearful</p><p>Independent Stubborn Difficult to Handle Likes Own Way Persistent</p><p>Shy Quiet Extremely Quiet Sensitive Gives Up Easily</p><p>Overactive Bouncy Angers Easily Easily Upset Unruffled</p><p>Easy Going</p><p>Others/additional comments: ______</p><p>______</p><p>______</p><p>2. Does your child have a fear of strangers? ______</p><p>If so, please explain: ______</p><p>______</p><p>3. When changes (i.e., routines, plans) occur, does your child adjust easily? ______</p><p>Does better when he/she knows in advance? ______</p><p>Does better without knowing? ______</p><p>4. Can your child take care of his/her personal toilet needs? ______</p><p>Control bathroom urgency? ______</p><p>Is bed wetting still occurring? ______</p><p>If so, please give more information: ______</p><p>5. Can your child work cooperatively with you? ______</p><p>6. Can your child adjust to being away from you for two to three hours without being upset?______PRESCHOOL CHECKLIST Page Four</p><p>7. Does your child play regularly with children his/her age? ______</p><p>Older children? </p><p>Younger children? </p><p>Please circle which group your child plays with the most: own age older younger</p><p>8. How does your child feel about going to school (i.e., eager, anxious)? Please explain.</p><p>LITERARY DEVELOPMENT</p><p>1. Does your child pretend to read? </p><p>2. How often is your child read to? </p><p>3. Can your child tell you a story from looking at the pictures? </p><p>4. Does your child pay attention when a story is read? </p><p>5. Can your child answer simple questions about a story that is read to him/her? </p><p>6. Does your child have a selection of books at home? </p><p>7. Do you and your child go to the public library? </p><p>8. Can your child read? PRESCHOOL CHECKLIST Page Five</p><p>INTERESTS AND ACTIVITIES</p><p>1. What are your child’s favorite inside activity(s)? </p><p>______</p><p>2. What are your child’s favorite outside activity(s)? </p><p>______</p><p>3. Does your child have a special interest? </p><p>______</p><p>4. What are your child’s favorite television shows? 1) 2) 3) </p><p>5. Does your child participate in any organized group activities (i.e., sports, dance, art, clubs)? If so, please explain/list: </p><p>______</p><p>CONCLUSION</p><p>Is there anything else we should know about your child to help him/her have a successful Preschool year?</p><p>______</p><p>______</p><p>______</p><p>______Home Language Survey (Parent/Guardian Language Questionnaire)</p><p>Name:______Age: _____ [first] [middle] [last]</p><p>Date of School Entrance______</p><p>Person completing the survey: [ ] Mother [ ] Father [ ] Grandparent</p><p>[ ] Guardian [ ] Other ______</p><p>Directions: Check or write in the correct response for each of the following questions about your child.</p><p>1. What language did the child learn when he/she first began to talk?</p><p>English______Other [specify]______</p><p>2. What language does the family speak at home most of the time?</p><p>English______Other [specify]______</p><p>3. What language does the parent [guardian] speak to the child most of the time?</p><p>English______Other [specify]______</p><p>4. What language does the child speak to his/her parent [guardian] most of the time?</p><p>English______Other [specify]______</p><p>5. What language does the child speak to her/her brothers and sisters most of the time?</p><p>English______Other [specify]______</p><p>6. What language does the child speak to his/her friends most of the time?</p><p>English______Other [specify]______</p><p>7. In which language do you wish to receive school communication?</p><p>English______Other [specify]______</p><p>Signature:______Date:______[person completing the survey]</p><p>*Adapted from the sample survey in A Manual for Community Representatives of the Title VI Steering Committee, published 9/76 by the Institute for Cultural Pluralism, Lau General Assistance Center, San Diego University, San Diego, CA 92182 Lebanon Borough School District 6 Maple Street Lebanon, New Jersey 08833 </p><p>Telephone: (908) 236-2448 Facsimile: (908) 236-7670</p><p>Dr. Robert Sutter Chief School Administrator</p><p>PRESCHOOL HEALTH HISTORY</p><p>NAME:______DOB:______SEX:______PARENTS’NAMES:______PHONE:______HEARING PROBLEMS-YES/NO IF YES, EXPLAIN:______FREQUENT or PROLONGED EARACHES-YES/NO # PER YEAR:______USES HEARING AIDS: YES/NO HISTORY of EAR TUBES/WHEN:______SPEECH PROBLEMS: YES/NO IF YES, EXPLAIN:______VISION: GLASSES______FREQUENT HEADACHES:______SITS CLOSE TO T.V. - YES / NO SQUINTS TO READ or WATCH T.V.______ALLERGIES: Medication______Food______Asthma______Seasonal ______Bee/Insect______Other______CURRENT MEDICATIONS:______HISTORY of HIGH FEVERS- YES / NO WHEN:______SEIZURES - YES / NO COMMUNICABLE DISEASES/ILLNESSES: PLEASE GIVE DATES ______Measles ______Strep Throat ______Epilepsy ______German Measles______Lymes ______Pneumonia ______Chicken Pox ______Diabetes ______Impetigo ______Mumps ______Heart Murmur______Eczema ______Rheumatic Fever______Frequent Colds ______Other</p><p>HEAD INJURY: HOW OCCURRED______DATE:______TREATMENT______FRACTURES: SITE______DATE______HOSPITALIZATIONS/OPERATIONS with DATES:______NUTRITION/FEEDING HABITS: Eats Well at Meals - Yes / No Frequent Snacks - Yes / No Food Sensitivities - Yes / No Explain______Vegetarian Diet - Yes / No</p><p>List any factors during your pregnancy or in the early life of your child that you think have affected his/her development.______Please circle if appropriate: Prematurity Low Birth Weight Bed-wetting Was any evaluation done by the Child Study Team as a preschooler? Yes / No PARENT SIGNATURE______DATE______</p><p>Lebanon Borough School District </p><p>6 Maple Street Lebanon, New Jersey 08833 </p><p>Telephone: (908) 236-2448 Facsimile: (908) 236-7670</p><p>Dr. Robert Sutter Chief School Administrator</p><p>PRESCHOOL PHYSICAL EXAM FORM To be completed by your private physician</p><p>NAME:______DOB:______SEX:______PARENTS’ NAMES:______PHONE:______ADDRESS:______HEIGHT:______WEIGHT:______BP:______</p><p>ALLERGIES(Medications, Food, Bees, Pollen, etc.):______</p><p>EYES: VISUAL ACUITY: RIGHT______LEFT______GLASSES______STRABISMUS______HEADACHES:______EARS: SWEEP CHECK: RIGHT______LEFT______RECURRENT OTITIS MEDIA______EAR TUBES______</p><p>NOSE:______THYROID:______MOUTH / TEETH: (SORES, CAVITIES) ______LYMPH NODES:______HEART:______ABDOMEN:______HERNIA:______LUNGS:______ASTHMA:______GENITOURINARY:______DESCENDED / UNDESCENDED TESTICLES ORTHOPEDIC: ______SCOLIOSIS:______SPEECH DIFFICULTY:______</p><p>PAST SURGERY/ HOSPITALIZATIONS:______MEDICATIONS: (STANDING or P.R.N.):______ANY RESTRICTION ON PLAY OR PHYSICAL EDUCATION ACTIVITIES? ______RECOMMENDATIONS / REFERRALS:______</p><p>PRINTED NAME OF PHYSICIAN:______SIGNATURE OF PHYSICIAN:______DATE:______</p>