Date sent _______________

Date Received ___________

Early Entrance to Kindergarten Application

Applicant’s Name: ______________________________________ Date of birth:______/______/______

Street Address: ______________________________________Telephone: _______________________ City: _______________________________________________ Zip Code: ________________________ Gender: Female ____ Male ____
With whom does the applicant live? ______________________________Relationship: ______________ Mother’s name: _______________________________________________________________________ Home phone: ____________________ Work: ____________________ Cell: ______________________ Address (if different than above): _________________________________________________________ Father’s name: _______________________________________________________________________ Phone: _____________________ Work: ________________________ Cell: ______________________ Address (if different than above): _________________________________________________________ Does your child receive preschool special education services? Yes ___ No ___
List the student’s siblings:

Name of sibling | Age | Sex | Grade

List the preschools, Head Start, special education program, and/or other child care programs attended. Include the dates of attendance and the approximate number of hours per week attended.

Name of School/Program | Dates of Attendance | # of Hours/Week

THIS APPLICATION AND THE TEACHER RECOMMENDATION MUST BE HAND DELIVERED BY THE PARENT TO THE PRINCIPAL OF THE SCHOOL YOUR CHILD WILL BE ATTENDING NO LATER THAN APRIL 30 PRIOR TO THE SCHOOL YEAR YOU ARE REQUESTING EARLY ENTRANCE
By signing below, you are giving the Madison Local Schools permission to evaluate your child to determine if he/she is eligible for early entrance to kindergarten.

Signature _________________________________________________ Date ___________________

Student Name: __________________________________________ Date of Birth: _______________

We seek to identify children who demonstrate a readiness for a full-day kindergarten program at this time. We gather and examine a variety of information from parents and teachers. We are aware that some children are very bright, but may not be developmentally ready for this program at this time. We want your child to be in an educational environment where he or she is comfortable and will thrive. When responding to the questions below, please mark how frequently your child exhibits the behavior. Space has been provided to give specific examples of behaviors that are often or almost always displayed.

1. My child is an avid reader or loves being read to. If the child can read, please indicate what age he or she started reading and list some books or print your child is able to read.

Seldom	Sometimes	Often	Almost Always

2. My child uses advanced vocabulary and expresses himself/herself well.

Seldom	Sometimes	Often	Almost Always

3. My child retains a great deal of information.

Seldom	Sometimes	Often	Almost Always

4. My child is a keen observer, gets more from a story, film or situation than others do.

Seldom	Sometimes	Often	Almost Always

5. My child sees relationships among unrelated ideas.

Seldom	Sometimes	Often	Almost Always

6. My child has a wide range of interests.

Seldom	Sometimes	Often	Almost Always

7. My child reasons things out for self, sees common sense answers.

Seldom	Sometimes	Often	Almost Always

8. My child shows rapid insight into “how” and “why” relationships.

Seldom	Sometimes	Often	Almost Always

9. My child is very inquisitive, curious.

Seldom	Sometimes	Often	Almost Always

10. My child has a keen sense of humor, finds humor where others don’t see it.

Seldom	Sometimes	Often	Almost Always

11. My child solves problems in a variety of ways and is often innovative.

Seldom	Sometimes	Often	Almost Always

12. My child is a high risk-taker: impulsive, adventurous and speculative.

Seldom	Sometimes	Often	Almost Always

13. My child is individualistic and likes to spend time alone.

Seldom	Sometimes	Often	Almost Always

14. My child organizes and directs activities in which he/she is involved.

Seldom	Sometimes	Often	Almost Always

15. My child is especially sensitive to others and to situations.

Seldom	Sometimes	Often	Almost Always

16. My child likes to take advantage of enrichment activities.

Seldom	Sometimes	Often	Almost Always

Social and Emotional Development

1. Is your child able to take care of his/her own personal belongings, such as: lunch	sweater	boots	coat	backpack	toys
Comments: ______________________________________________________________ 2. Can your child be left with a babysitter without making a fuss?
Yes	Most of the time	No

Comments: ______________________________________________________________

3. Can your child be away from you for a whole day without becoming upset?

Yes	Not at this time	Don’t know yet

Comments: ___________________________________________________________________ 4. How well does your child react when plans change?

Becomes upset	cries easily	accepts change without becoming upset Comments: ___________________________________________________________________

5. How well does your child change from:

Easily	Not Very Easily	Not well at this time

One adult to another One place to another One task to another

6. Is your child able to easily share things such as:

Yes, most of the time	Seldom	Not at this time Food
Toys Pencils/Crayons/Paper Clothing

7. Is your child able to make friends easily?

Yes, most of the time	Not at this time

Comments: _________________________________________________________________

8. Does your child know how to take turns with other children?

Yes, most of the time	Some of the time

At this time he/she has difficulty keeping friends

Comments: _________________________________________________________________

9. Does your child seem to play well with other children?

Yes, most of the time	Some of the time

At this time he/she has difficulty playing with other children

Comments _________________________________________________________________

10. Is your child able to “work” cooperatively with other children on a task?

Yes, most of the time	Some of the time

At this time he/she has difficulty “working” cooperatively on a task with others Comments: ____________________________________________________________

11. Can your child sit still for a short period of time to:

Yes	Not at this time

Listen to a story? Be read to?
Do a simple task?

Comments ________________________________________________________________________

12. How does your child respond to criticism or correction?

Student thoughtfully considers feedback and criticism and modifies behavior appropriately
Student is very sensitive to criticism or remarks

Student reacts aggressively and/or defensively when criticized

Comments _______________________________________________________________________

Please describe why you are interested in early kindergarten entrance for your child.

THIS APPLICATION AND THE TEACHER RECOMMENDATION MUST BE HAND DELIVERED BY THE PARENT TO THE PRINCIPAL OF THE SCHOOL YOUR CHILD WILL BE ATTENDING, NO LATER THAN APRIL 30^TH PRIOR TO THE SCHOOL YEAR YOU ARE REQUESTING EARLY ENTRANCE.