Kindergarten Communication Questionnaire - peelschools.org

1 Kindergarten Communication Questionnaire This information will be used by Peel District School Board staff to better meet the needs of your child. Child's Name: Child's Date of Birth: (yyyy/mm/dd). Parent Name: Parent Phone Number: Languages Spoken in the Home: Please answer the following questions based on the language that you and your child speak at HOME: 1. What age did your child begin to talk using single words? ( , "no," "more") _____. 2. Did your child combine words by two years of age and use simple sentences by three years of age? Yes No 3. Does your child speak in complete sentences using age-appropriate grammar? Yes No 4. Does your child stutter, stammer or struggle to get words out when talking? ( , repeats words many times; stretches or repeats the first sound in a word such as mmmmmmme or c-c-c-c-cat) Yes No 5.

2 Can your child talk about things they or others have done in the right order? Yes No 6. Can your child follow 2-3 simple directions given at once? ( , "Put your blocks away, turn off the TV and get your coat.") Yes No 7. Can your child ask and/or answer questions correctly? Yes No 8. Does your child pronounce words clearly in his/her HOME language similar to others his/her age? Yes No 9. Do people outside the family understand most of what your child says? Yes No 10. Does your child engage in step-by-step pretend play? ( , pretending to be a teacher, pretending to give a doll a bath) Yes No 11. Has your child ever received speech/language support? ( , Erinoakkids, private speech and language services, etc.) Yes No If yes, is there a report you can share with the school?

3 Yes No 12. Do you have any concerns about your child's speech and language development? Yes No If yes, please describe_____. _____. _____. SLP see reverse Kindergarten Registration Questionnaire (Revised October 2015) Page 1. Please share any additional information that would help us get to know your child. _____. _____. _____. _____. SCHOOL USE ONLY. Reviewed by School SLP _____. SLP Follow-up: Called parent to discuss information Referred parent to community resources ( , Ontario Early Years Centre, Child and Family Resource Centre, etc.). Referred parent to ErinoakKids Suggested hearing evaluation Suggested medical follow-up Provided resources to parents Other Any other additional information: SLP see reverse Kindergarten Registration Questionnaire (Revised October 2015) Page 2.

4 Parent Registration Checklist In all instances, ORIGINAL documentation or officially certified true copies must be presented. Student Currently Registered with the Peel District School Board ~ Required: . Transfer form (Elementary) or Status Sheet (Secondary) from previous Peel District School Board school . Proof of Address (see list below).. Completed Registration Form Student Not Currently Registered with the Peel District School Board ~ Required: . Proof of child's age (present one original document from the list below). Canadian Birth Certificate/Birth Registration Card Canadian Citizenship Card / Certificate / Passport Permanent Resident Card / Confirmation of Permanent Residence Work permit/Employment Authorization from Citizenship and Immigration Canada Study Permit issued to parent for a diploma or degree program from Citizenship and Immigration Canada Refugee/Convention Refugee Permit Visitor Permit for Missionary Work (only case type 13).

5 Proof of address (present one original document from the list below). Ontario Driver's Licence Utility Bill (water, hydro, gas, phone, cable, cell phone). Bank Statement/Letter from Financial Institution Credit Card Statement Government forms ( Social Insurance Number, Service Canada documents). Purchase Agreement . Proof of immunization Students registering in an Ontario public school for the first time must provide proof of immunization/vaccination Students with an Ontario Education Number (shown on Ontario report cards or transcripts) do not need to provide proof of immunization . Proof of custody children must live with their parent(s) unless provided documentation supports an alternate living arrangement . Proof of education For Elementary students who are currently attending school in Ontario, please bring the most re- cent report card For Secondary students who are attending or have attended secondary school in Ontario, please bring the most recent transcript, report card or credit summary report (if available).

6 Notify school at time of registration if your child is registered currently in a specialized program such as SHSM (include sector), IB, IBT, FI, EF, ELL or other programming Provide a copy of your child's most recent IEP, if applicable.. Completed Registration Form March 2017 1 STUDENT REGISTRATION FORM. SHADED AREAS FOR SCHOOL USE ONLY. STUDENT NUMBER (If Transfer) ONTARIO EDUCATION NUMBER (OEN) GRADE/HOME FORM ADMISSION DATE (yyyy mm dd) GR 9 ENTRY DATE (yyyy mm dd) STUDENT INFORMATION. LEGAL LAST NAME LEGAL FIRST NAME MIDDLE NAME GENDER MALE USUAL LAST NAME PREFERRED FIRST NAME BIRTH DATE (yyyy mm dd) FEMALE OTHER RESIDENTIAL ADDRESS HOME PHONE NUMBER UNLISTED APT. NO. STREET/EMERGENCY NUMBER STREET NAME/LINE OR SIDE ROAD ( ) YES BOX TOWN/CITY PROVINCE POSTAL CODE MAILING ADDRESS.

7 APT. NO. STREET NUMBER STREET NAME/LINE OR SIDE ROAD IIF DIFFERENT THEN RESIDENTIAL ADDESSS BOX TOWN/CITY POSTAL CODE GENERAL STUDENT INFORMATION (Must be completed in full). PREVIOUS SCHOOL DISTRICT PREVIOUS SCHOOL NAME PREVIOUS SCHOOL ADDRESS PROOF OF AGE & NAME (copy for OSR) CANADIAN CITIZENSHIP CARD FOR FUNDING PURPOSES ONLY CDN. BIRTH CERTIFICATE/ PERMANENT RESIDENT CARD/FORM Country of Birth Province/Territory 1st Entry Date into If Canada Canada (yyyy mm dd) REGISTRATION CARD OTHER IMMIGRATION DOC _____ CDN. PASSPORT _____ _____ _____ WAS ENGLISH FIRST LANGUAGE STUDENT LANGUAGES STUDENT SPEAKS AT HOME _____ _____ _____ LEARNED AT HOME? YES NO VOLUNTARY AND CONFIDENTIAL SELF IDENTIFICATION FOR FIRST NATION, M TIS, AND INUIT STUDENTS FIRST NATION M TIS INUIT HEALTH FACTORS (Must be completed in full).

8 HEALTH FACTORS MEDICATION REQUIRED ASTHMA Life Threatening YES NO ALLERGIES _____ Life Threatening YES NO AT SCHOOL? YES NO SEIZURES Life Threatening YES NO OTHER _____ Life Threatening YES NO If YES Medica on Form must be DIABETES Life Threatening YES NO _____ Life Threatening YES NO completed PARENTAL INFORMATION (Must be completed in full). CUSTODY *Documents Required LIVING WITH BOTH PARENTS *FATHER ONLY *SELF (16 & OVER) BOTH PARENTS FATHER ONLY SELF *MOTHER ONLY *LEGAL GUARDIAN(S) *CHILDREN'S AID SOCIETY MOTHER ONLY LEGAL GUARDIAN(S) FOSTER PARENT(S) Last Name First Name Speaks English MOTHER GUARDIAN FATHER SELF YES NO Home Phone Number Cellular Number Business Phone Number (including Ext.) E mail Address *. ( ) ( ) ( ) Last Name First Name Speaks English MOTHER GUARDIAN FATHER SELF YES NO Home Phone Number Cellular Number Business Phone Number (including Ext.)

9 E mail Address *. ( ) ( ) ( ) Address if different from student (include street number, name, city and postal code) If parent is deceased: Mother Date of Death _____ Father Date of Death _____ 2 SIBLING INFORMATION (Must be completed in full). LAST NAME FIRST NAME RELATIONSHIP TO STUDENT DATE OF BIRTH SCHOOL & GRADE BROTHER SISTER BROTHER SISTER BROTHER SISTER BROTHER SISTER BROTHER SISTER . For addi onal siblings, please add siblings on a separate sheet of paper and include with registra on form ADDITIONAL FAMILY INFORMATION OF WHICH SCHOOL SHOULD BE AWARE: PLEASE ADVISE IF ALTERNATE Communication ( HARD OF HEARING, LARGE PRINT, BRAILLE, SIGN LANGUAGE) REQUIRED EMERGENCY CONTACTS IF PARENT(S)/GUARDIAN(S) UNAVAILABLE IN ORDER OF AVAILABILITY (#1 EASIEST TO CONTACT) 1.

10 LAST NAME 2. LAST NAME 3. LAST NAME FIRST NAME FIRST NAME FIRST NAME RELATIONSHIP TO STUDENT: RELATIONSHIP TO STUDENT: RELATIONSHIP TO STUDENT HOME PHONE NUMBER CELLULAR NUMBER HOME PHONE NUMBER CELLULAR NUMBER HOME PHONE NUMBER CELLULAR NUMBER ( ) ( ) ( ) ( ) ( ) ( ) BUS. PHONE NUMBER & EXTENSION SPEAKS ENGLISH BUS. PHONE NUMBER & EXTENSION SPEAKS ENGLISH BUS. PHONE NUMBER & EXTENSION SPEAKS ENGLISH. ( ) YES NO ( ) YES NO ( ) YES NO *CONSENT TO RECEIVE ELECTRONIC Communication FROM THE PEEL DISTRICT SCHOOL BOARD.. I hereby consent to receive electronic communica on from the Peel District School Board at the email address I have provided. I understand this consent will be e ec ve for the dura on of my child's educa on at the board.