Kindergarten registration forms - Brentwood Borough School District

BRENTWOOD BOROUGH SCHOOL DISTRICTENROLLMENT RECORD3601 Brownsville RoadPittsburgh, Pennsylvania 15227All information provided on this form will be kept in a confidential file. Access to this file is limited to school personnel.Please supply documented proof of immunization (Physician's Record) and age (original birth certificate). These documentswill be photocopied by the school official.STUDENT INFORMATION:STUDENT NAME:LAST FIRST M.I.HOME ADDRESS:TELEPHONE: SOCIAL SECURITY NO.: - -SEX: DATE OF BIRTH: - -DATE OF ENTRANCE:GRADE ENTERING:Please list previous schools, beginning with last one attended, include pre-school and nursery schools:SCHOOL ADDRESS GRADEDid the child repeat any grades?If yes, what grades?Did the child receive any of the educational services listed below at previous schools?If so, please check the service and indicate the grade or grades.SERVICE GRADE SERVICE GRADESPEECH/LANGUAGE/ESLVISION THERAPYCOUNSELINGPSYCHOLOGICAL TESTINGGIFTED AND TALENTEDTRANSITIONAL CLASSESHEARING THERAPYREMEDIAL READINGREMEDIAL MATHLEARNING SUPPORTEMOTIONAL SUPPORTEXTENDED DAY CLASSES