ANDOVER REGIONAL SCHOOL DISTRICT KINDERGARTEN REGISTRATION DATA

NAME ______________________________________________ AGE _______

LAST_______________________________________________

FIRST______________________________________________

MIDDLE____________________________________________

DATE OF BIRTH ________________________________

PRESENTED BIRTH CERT. _______

SEX - M ______ F _______ RACE - _______ Codes - 1 = White; 2= Black; 3= Hispanic;

4=American Indian/Alaskan Native; 5= Asian/Pacific Island

FATHER'S NAME ___________________________________________________

MOTHER'S NAME __________________________________________________

PARENTS' MARTIAL STATUS ________________________________________

ANY LEGAL RESTRICTIONS ON WHOM MAY PICK UP CHILD FROM SCHOOL?

IF SO, PLEASE IDENTIFY BELOW. (State of New Jersey requires verification of this request.)

____________________________________________________________________

TO WHOM SHOULD CORRESPONDENCE BE ADDRESSED? _______________

____________________________________________________________________

MAILING ADDRESS __________________________________________________

LOCATION OF HOUSE _______________________________________________

IS HOUSE LOCATED IN TOWNSHIP _________ BOROUGH _________

HOME PHONE __________________ EMERGENCY PHONE ________________ 

FATHER'S OCCUPATION ________________________ EMPLOYED ___________

EMPLOYER PHONE#______________________

MOTHER'S OCCUPATION _______________________EMPLOYED ____________

EMPLOYER PHONE#____________________________ 

NATIVE LANGUAGE SPOKEN IN HOUSEHOLD ____________________________

PRESCHOOL ATTENDED (IF ANY) _______________________________________

BROTHERS OR SISTERS IN SCHOOL: (LIST NAME, CLASSROOM AND BUS ROUTE)

1________________________________ 2. ______________________ 3. ___________________

4. ______________________

DOES YOUR CHILD HAVE ANY PHYSICAL LIMITATIONS? IF SO, PLEASE EXPLAIN

_______________________________________________________________________________

DATE OF REGISTRATION ________________________________________ __________________________________________________________________________