NEW STUDENT REGISTRATION Lewis-Palmer School District

146 Jefferson St., P.O. Box 40

Monument, CO 80132-0040

Phone: 719-488-4700 Fax: 719-785-4218

Preschool Registration

This packet contains documents and information for registering your child for preschool in

Lewis-Palmer School District. When you turn in the completed forms, please provide the

following additional documents. The registration office will not process the registration if

any of the required documents are missing.

Verification of Address. Acceptable forms of address verification include one of

the following. If you are living with friends or relatives, they should provide a

signed note stating this and supply their address verification:

o Warranty Deed

o Signed Contract with Name, Address, and Closing Date

o Settlement Statement from Closing

o Current El Paso County Tax Notice

o Construction Loan Statement

o Signed Contract with Builder

o Building Permit

o Current Rental or Lease Agreement

o Current Utility Bill

Student’s Immunization Record (not required for returning students if there are no

updates)

Student’s Registered County Birth Certificate (not required for returning

students)

Custody Documentation or Power of Attorney (if the student does not reside with

the parent)

Special Education IEP (if applicable and coming from another school district)

Photo Identification of Parent or Legal Guardian

$50 non-refundable registration fee (not applicable for students receiving special

education services or those who are applying for tuition assistance through the

Colorado Preschool Program).

* PLEASE NOTE:

Preschool students must be 3 years old and toilet trained to start preschool.

Students who turn 5 years old by October 1 are eligible for kindergarten and may

not enroll in preschool. Exceptions to this policy are made with building principal

approval.

LEWIS-PALMER SCHOOL DISTRICT PRESCHOOL REGISTRATION FORM PLEASE PRINT CLEARLY Start Date:

Student’s Legal Name: (Last Name) (First Name) (Middle Name)

Grade Gender M F Place of Birth Birth Date

Ethnicity (choose one):

Hispanic/Latino (a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race) Not Hispanic/Latino

AND

Race (chose one or more):

American Indian or Alaskan Native (A person having origins in any of the original peoples of North, Central, or South America, and who maintains cultural identification through tribal affiliation or community recognition)

Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam)

Black or African American (A person having origins in any of the black racial groups of Africa)

Native Hawaiian or Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands)

White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa)

Male Head of Household: Employer: (Last Name) (First Name)

Phone Hm: Wk: Cell: Email:

Female Head of Household: Employer: (Last Name) (First Name)

Phone Hm: Wk: Cell: Email:

Street Address: (Number) (Street) (Apt #) (City) (State) (Zip)

Mailing Address: (If different) (Number) (Street) (Apt #) (City) (State) (Zip)

Names of other Children in the Household (please include preschool):

(Last Name) (First Name) (Middle Name) (Birth Date) (Grade)

(Last Name) (First Name) (Middle Name) (Birth Date) (Grade)

(Last Name) (First Name) (Middle Name) (Birth Date) (Grade)

Emergency Contacts: The individuals below live locally, have authorization to pick up my student, and can be reached during school hours:

(Last Name) (First Name) (Relationship) (Phone)

(Last Name) (First Name) (Relationship) (Phone)

Has your child ever been enrolled in a Colorado School? Y N Has your child been enrolled in this district before? Y N

Has your child ever been assigned to any special programs? Y N If yes, please specify:

Would you like to be contacted by the Special Education Parent Liaison? Y N

Last school attended: (Name) (Address)

I give permission to my preschool staff to obtain/provide emergency medical

care for my child. This may include arranging transportation to the nearest

hospital facility for emergency care and any costs associated with such care. (Parent/Guardian Signature) (Date)

FOR OFFICE USE

School Assignment: Contact/Phone: Transportation: 488-4711

Copies to: Parent/Guardian School SPED (IEP) Accounts Payable

(Original maintained at District Administration) Information entered by

Relationship to Student: Legal Guardian? Y N Resides With? Y N

Relationship to Student: Legal Guardian? Y N Resides With? Y N

DISTRICT #38 PRESCHOOL PROGRAMS SELECTION FORM FOR

2020-2021 SCHOOL YEAR

Age of student by October 1, 2020 ____ years ____ months ___ Male ___ Female

Please note: if your student is five years old on October 1, 2020, he or she has reached the

minimum age for kindergarten and is not eligible to enroll in the preschool/preK program.

Exceptions to this policy are made with building principal approval.

Student’s Name Date of Birth

Parent’s Name Neighborhood School

Address Zip

Phone: Home Cell Work

School Program Preference:

PALMER LAKE EARLY CHILDHOOD CENTER

106 North Jefferson Street in Monument

(AM classes 8:30 – 11:30, PM class 12:30 – 3:30)

□ 4 days M-TH (PreK), indicate 1st & 2nd choice

AM FULL PM FULL

□ 2 or 4 days (mornings 3&4 yrs preschool)

M/W FULL T/Th FULL M-Th FULL

□ 2 or 4 days (afternoon 3&4 yrs preschool)

M/W FULL T/Th FULL M-Th FULL

LEWIS PALMER ELEMENTARY no preschool at this site

PRAIRIE WINDS ELEMENTARY

no preschool at this site

BEAR CREEK ELEMENTARY

1330 Creekside Drive

(AM classes 8:55 – 11:55, PM classes 12:40 – 3:40)

□ 4 days M-TH (PreK), indicate 1st & 2nd choice

AM _____ PM _____

□ 2 or 4 days (mornings 3&4 yrs preschool)

M/W _____ T/Th FULL M-Th FULL

□ 2 or 4 days (afternoon 3&4 yrs preschool)

M/W _____ T/Th _____ M-Th _____

KILMER ELEMENTARY

4285 Walker Road

(AM class 8:45 – 11:45, PM class 12:40 – 3:40)

□ 4 days (afternoons) M-TH, (PreK) _____

□ 2 or 4 days (mornings 3&4 yrs preschool)

M/W _____ T/Th _____ M-Th _____

Program notes:

1. Students who turn four years old by Oct 1 are considered PreK and are assigned to the 4-day preK program.

Younger students (3&4 years old) can elect either a 2-day or 4-day preschool program.

2. For the 2-day option, students will be placed on a wait list and notified of seat availability after March 1, 2020.

The purpose is to maximize use of available preschool seats.

3. Students who turn five years old by Oct 1 are considered kindergarten-aged and are not eligible to enroll in the

preschool/preK program. Exceptions to this policy are made with building principal approval.

4. Special Education services are provided during the preschool classroom sessions. Your student may be

assigned a preschool location and session based on service availability.

5. While we do our best to accommodate your program preference, students are enrolled on a first come basis.

Because of limited programming capacity, seats may not be available at some locations.

Parent’s Signature Date

DISTRICT #38 PRESCHOOL TUITION INFORMATION

2020-2021 SCHOOL YEAR

Student Name: Date of Birth (mm/dd/yy):

Billing Address:

Tuition and fees are subject to Board of Education approval and may be adjusted. There are no

reductions for scheduled holidays, snow days, or other building emergencies, and there are no

program modifications made for preschool.

o 4-days: Mon-Thu, morning or afternoon, 3 hours/day: $315/month

o 2-days: M/W or T/Th, mornings or afternoons, 3 hours/day: $180/month

The Colorado Preschool Program (CPP) offers financial assistance for preschool tuition to

qualifying families in the Tri-Lakes area. Contact Melissa Gibson-Steiner, CPP Family Advocate

at MGibson-Steiner@lewispalmer.org or 719-368-1089 for more information or to apply.

Note: in order to maximize use of available seats, parents selecting the 2-day option will be

notified of seat availability after March 1, 2020.

A $50 non-refundable registration fee is due at the time of enrollment. Note: this is not required

for students who are receiving special education services or those who are applying for tuition

assistance through the Colorado Preschool Program (CPP).

There are a total of nine monthly payments for the entire school year. Payment is due the first of

the month. As a courtesy, you will be emailed a monthly notification beginning at the end of

July, which will be due August 1 (or the first month your child attends school). Payment is due

whether you receive your invoice or not. If you don’t receive your invoice, please contact Karen

Alfultis at 719-785-4220 or KAlfultis@lewispalmer.org. Payment methods include:

o Credit or debit card using your Infinite Campus Parent Portal Account

o Checks payable to LPSD #38 and mailed to:

Please note: credit card payments processed over the phone or at the Administration

Building incur an additional $3 fee

Late Payments: Your account may be assessed a $25 late payment fee if payment is not

received by the 10th of the month. If your account is 30 or more days past due, your child

may be ineligible to attend until the past due account is satisfied.

Non-Sufficient Funds: If your check is returned for non-sufficient funds, your account may

incur a $10 NSF fee, in addition to a possible $25 late payment fee.

My signature below indicates I have read and understand the information above.

Parent/Guardian Name Signature Date

Office Use

School: Program: 2-Day or 4-Day Start Date: Initials:

Deposit Information: Payment Amount: Method: Date:

LPSD Accounts Payable

PO Box 40

Monument, CO 80132

Lewis-Palmer School District #38 Home Language Survey

Required by the Office of Civil Rights Federal and state regulations require schools to determine the language(s) spoken and understood by each student. This information is requested so that schools may provide appropriate instruction.

TO BE FILLED OUT BY PARENT/GUARDIAN:

Student’s Name (Last) __________________________ (First) _________________________ (Middle) ______________ Date of Birth_____________ Parent/Guardian Name _______________________________________ What language(s) did your child use when he/she first began to speak? ___________________________________________________________________________________ What language(s) is spoken to the child by the following people? Mother__________ Father ___________ Siblings ___________ Others in the home ______________ What language(s) does your child speak to you at home/how often? ____________________________________________________________________________________ Do the adults in your home (parents, guardians, grandparents, others) speak to each other in a language

other than English all or part of the time? □ Yes □ No

If yes, what language(s) are spoken/how often? ____________________________________________________________________________________ Child’s Country of Birth_______________________________________________________________ Date Child entered Colorado _______________ Date child entered USA ______________________

Can information from the school be sent home in English? □ Yes □ No

IF A LANGUAGE OTHER THAN ENGLISH HAS BEEN INDICATED ABOVE, YOUR CHILD’S ENGLISH PROFICIENCY MAY BE TESTED. PLEASE CONTINUE: Does your child understand the conversations between adults in the home when they are speaking a

language other than English? □ Yes □ No

Does your child participate in the conversation even though he/she might use English? □ Yes □ No

What language(s) does your child read? _________________________________________________ What language(s) does your child write? _________________________________________________

Did your child ever attend school in another country? □ Yes □ No

If yes, in which country, and what grades? _______________________________________________ What language(s) were used for instruction? _____________________________________________

Parent or Guardian Signature ___________________________________________________ Date ___________________

To be filled out by registration staff:

School _________ Grade _____ Start Date ________________ Copied to ELL Coordinator _________ Date Received By ELL Coordinator ________________________ Notes:

Original to be kept in student’s cum file Revised 3/12/10

Lewis Palmer District 38 Preschool

Authorization to Transport

Child’s Name:

Parent’s Names:

Home Phone: Cell:

The following people are authorized to transport my child to/from preschool:

Name Relationship Phone Address

The following people may NOT transport my child to/from preschool:

Name Relationship Phone

The preschool staff will be notified of any changes.

Parent’s Signature Date

**I.D. will be required for unfamiliar people**

Lewis-Palmer School District 38 Preschool

In each section, mark your choice. Please sign at the bottom. If completing this separately from

the preschool enrollment packet, please return to your child’s preschool.

Child’s Name:

I give permission for my child to be photographed and/or videotaped by Lewis-Palmer

School District 38 for educational, informational, and programming purposes including

the school web page and training media.

I do NOT give permission for my child to be photographed and/or videotaped by Lewis-

Palmer School District 38 for educational, informational, and programming purposes

including the school web page and training media.

I give permission for my telephone number/email to be shared with other parents and/or

guardians in my child’s preschool class.

I do NOT give permission for my telephone number/email to be shared with other

parents and/or guardians in my child’s preschool class.

I give permission for my child to be photographed for yearbook purposes.

I do NOT give permission for my child to be photographed for yearbook purposes.

I give permission for photos of my child to be viewed by families of children in my

child’s class.

I do NOT give permission for photos of my child to be viewed by families of children in

my child’s class.

I give permission for my child to accompany the preschool class on walks in, near, or

around the school building.

I do NOT give permission for my child to accompany the preschool class on walks in,

near, or around the school building.

I agree to apply sunscreen to the bare surfaces on my child before attending preschool. I

understand it is my responsibility to apply sunscreen with a minimum SPF of 15 when

my child is participating in outdoor activities.

I do NOT agree to apply sunscreen to my child when participating in outdoor activities.

In the event of an early dismissal from school, my child will be picked up as usual.

In the event of an early dismissal from school, my child needs to:

I have read the handbook and understand the policies and procedures of the preschools of Lewis-

Palmer School District 38. I have also been made aware and authorize the school to allow my

child to view (on occasion), materials on video/television relating to the preschool’s weekly

teaching themes.

Parent Signature Date

Emergency Information

Student’s Name:

Date of Birth:

Parent/Guardian #1

Name:

Address:

Home Phone:

Work Phone:

Cell Phone:

Relationship:

Employer:

Address:

Parent/Guardian #2

Name:

Address:

Home Phone:

Work Phone:

Cell Phone:

Relationship:

Employer:

Address:

Emergency Contact #1 Emergency Contact #2 (Other than the parent/guardian) (Other than the parent/guardian)

Name: Name:

Address: Address:

Home Phone: Home Phone:

Work Phone: Work Phone:

Cell Phone: Cell Phone:

Relationship: Relationship:

Updated 12/2017

Lewis-Palmer School District 38 Health Information Form

(Must be completed annually)

Student’s Name:___________________________________________ Birthdate _______________ Grade _________

Parent Name(s): _________________________________________ Preferred Hospital __________________________

CIRCLE all CURRENT conditions listed below for your child

ADD/ADHD Blood Disorder Diabetes (pen/pump/CGM) Migraines

Allergies Bone/Joint Developmental Delays Seizures Type_____________________

Asthma Bowel/Bladder Head Injury/Concussion Stomach

Autism Depression Hearing Loss Other: _________________________

Please describe above circled conditions:

Please list any CURRENT medical diagnosis:

Is your child taking any routine medications? YES / NO

If YES, please list: Med Name/Dose/Time Taken _________________________________________________________________

Med Name/Dose/Time Taken _________________________________________________________________

Will your child take medication at school? YES / NO

Will your child self-carry any meds at school? (Prescription and/or OTC, 7-12th grades ONLY) YES / NO

(Please note: District 38 requires all students requiring medication to be given and/or self-carried at school, to have the Permission to

Administer Medication Form on file and renewed each school year signed by healthcare provider, parent and student if student is self-carrying.)

Does your child have any Life Threatening Allergies that school staff need to know about? YES / NO

If YES, please list allergy, reaction and date (month/year) of last reaction________________________________________________

Please circle one: I WILL or WILL NOT be providing school rescue medication such as epinephrine for severe allergy listed above.

I understand 911 will be called should an emergency arise.

Does your child have any dietary restrictions? YES / NO Please list: _________________________________________________

If YES, is restriction related to Food Allergy YES / NO Parent/Student preference YES / NO

Does your child wear glasses YES / NO Contacts YES / NO Have a known color vision defect YES / NO

Date of last vision exam (Month/Year) _____________ Eye Care Professional Name ______________________________________

Hospitalizations and/or surgeries (Month/Year/Description) ___________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

Student’s Physician Name/Address/Phone: _______________________________________________________________________

Student’s Dentist Name/Address Phone: _________________________________________________________________________

Medicaid? YES / NO Student’s Health Insurance Company: _______________________________________________________

I give permission for this information to be shared with adults in school setting who will be working with my child on a need-to-know

basis. It is the responsibility of the parent to notify the school nurse whenever there is any change in student’s health status or care and

ascertain any health information faxed/electronically sent to school by any outside sources have been received by the school

Form Completed by (Please Print): ________________________________________ Relationship to student: __________________

Parent/Guardian signature: ______________________________________________ Date: _________________________________

School Year ____________

HEALTH RECORD FOR LEWIS-PALMER SCHOOL DISTRICT #38

Children who enroll in preschool programs must submit a signed and dated statement of the child’s current health status which indicates the child’s abilities and/or limitations to participate in a regularly scheduled program of play in a group of young children. This report is to be filled out by a licensed physician or a licensed nurse practitioner who has seen the child in the last twelve months.

Child’s Name Sex Birth Date

Address Phone

Past Illnesses – check those that the child has had and give approximate dates:

□ Chicken Pox

□ Rheumatic Fever

□ Mumps

□ Poliomyelitis

□ Rubella

□ Hay Fever

□ Epilepsy

□ Rubeola

□ Asthma

□ Diabetes

□ Whooping Cough

□ Other

This child is is not physically or emotionally able to participate in the day care program named above.

Comments:

Surgery/Accidents/Illnesses/Chronic or Handicapping Problems/Prosthetic Devices:

Describe any physical condition requiring special attention by center staff:

Medication(s) prescribed:

Please submit physician’s order if medications are to be given at school.

Allergies that staff should be aware of

Prescribed routine:

If tuberculin test given: Date Result

If chest x-ray taken: Date Result

Vision Hearing

Please include any other pertinent information useful to service provider.

Please record immunizations and dates administered on the Colorado Department of Health Certificate of Immunization and attach to this form.

I hereby acknowledge there are no health concerns that would prohibit this child from attending preschool for the 2020- 2021 school year.

Signature of licensed physician or nurse practitioner Date

Please print name and address: