(This applies to children who turn 5/6 years old after September 1)
Child's Name: _______________________________ Sex: ____ Birth Date: _____________
Father's Name: _______________________________________________________________
Mother's Name: _______________________________________________________________
Address: _____________________________________________________________________
City/State: ____________________________________________ Zip Code: ___________
Telephone Number: (Home) _____________________ (Work) _______________________
Reason for Request: _____________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
I am requesting that my child be permitted early admission to kindergarten/ first grade. I give my permission for my child to be evaluated and tested by a certified School Psychologist and other school personnel, where appropriate, at no cost to me. I realize that if early admission is granted, the placement will be reviewed after six weeks to determine if it is, in fact, appropriate for my child.
________________________________ _______________________________
(Signature of Parent/Guardian) (Date)
________________________________ _______________________________
(Signature of Principal) (Date Received/Interviewed)
APPROVED: August 12, 1993
12/21/2004 pw