Kindergarten Round Up Information
Kindergarten Round-Up Registration Form
If your child will be 5 by September 15, 2013,
please return this completed form to your school office;Thomas Jefferson school office at: 792-2498, or email: email@example.com Thomas Jefferson,Newton, IA 50208orBerg Elementary school office at: 792-7742 or email: firstname.lastname@example.org
1900 N 5
Ave ENewton, IA 50208
All students need to register in their home attendance area. The electronic form will be on our school homepage.
If you know of any neighbors or friends who have children that should register for kindergarten round-up, please havethem contact the school in their area.
Student’s Legal Name ______________________________________________________________________
First Middle Last
Child’s Nickname ________________________________
____ Preschool __________________________Date of Birth ________________________________________ Gender ____________________________Month Day YearIs the student in Foster Care (Circle One): Yes No
Race/Ethnicity: 2 part Question:
Is the individual Hispanic/Latino? (Circle One)
Is the individual from 1 or more of these races (Circle all that apply):
American or Asian Indian Asian Black or African American Native Hawaiian or Pacific Islander White
Parent/Guardian _______________________________________________________________________ (Lives with)Address ______________________________________City, State, Zip ______________________Home Phone ___________________Other Numbers _______________________ cell work otherOther Numbers ______________________cell work other E-mail Address __________________________Emergency Contact _______________________________________________________________________Phone Number ___________________________________Relationship _________________________Medical Concerns _______________________________________________________________________
I currently have ______ child (ren) attending __________ SchoolNames/Grades___________________________________________________________
Thomas Jefferson’s Parent Night is March 14, 2013 at 6:00 pm in the gym. Berg’s
Parent Night is
March 11, 2013 at 6:00p.m. in the gym.
Please bring a copy of your