_________________________________________________________________________________________________ Gerard St. Amand, Principal

Meg Trainor, Assistant Principal ~ Janet Davis, Assistant Principal

Dear Parent/Guardian:

Enclosed is the registration packet for your child(ren) to attend the Clark-Wilkins Preschool. Please return the completed registration packet along with your deposit to the attention of Caroline Smith, Clark School, P.O. Box 420, Amherst, NH 03031.

The Clark-Wilkins Preschool program will run from Monday through Thursday. The three year old class will be held in the morning, from 8:30-11:15 am. The four year old class will be in the afternoons, from 12:00-2:45 pm. All classes will be held at Clark School on Foundry Street.

In addition to the completed registration information, we will also need:

• Your child’s original birth certificate (we will make a copy for our records)

• Copy of Immunization Records

• Copy of most recent physical or completed Child Health Form

• Certification of Address signed by Town Clerk

Since attendance is limited to 16 students per class, we are asking that you drop off or send registration packets to Clark School. The packets will be dated and time stamped upon receipt. You will receive a copy of the date and time stamp receipt for your records. The tuition registration form allows parents to choose the most convenient method of payment. Checks should be made out to the Amherst School District-Clark-Wilkins Preschool. The annual amount required for the four day – 11 hour a week program is $2,250. Please feel free to contact Caroline Smith, the Amherst Preschool Coordinator, at carolin.smith@sprise.com, or 603-673-2343 should you have any questions about the registration process or would like more information about the Clark-Wilkins Preschool.

Teresa April Office Manager Clark-Wilkins Elementary School

CLARK SCHOOL P.O. Box 420

14 Foundry Street Amherst, NH 03031

Tel: 603-673-2343 Fax: 603-672-5114

WILKINS SCHOOL P.O. Box 420

80 Boston Post Road Amherst, NH 03031

Tel: 603-673-4411 Fax: 603-672-0968

Amherst School District

Preschool Registration Form 2014.2015

Parent/Guardian Name:

Child’s Name: (Last, First)

Nickname:

Date of Birth:

Mailing Address:

City, State, Zip Code:

Home Phone: Email address:

Preferred Class: Please check the applicable class

Check Here Check Here

3 Year Old Preschool Class Monday – Thursday

8:30 a.m. – 11:15 a.m.

Child(ren) have reached 3 years old on

or before September 30th

4 Year Old Preschool Class Monday - Thursday

12:00 p.m. – 2:45 p.m.

Child(ren) have reached 4 years old

on or before September 30th

Tuition: $2250.00 (Please select your payment option)

3 & 4 Year

Olds

One Annual Payment of $2,150.00 for 4 day program

Semi-Annual Payments: 2 payments of $1,075.00 due on 1st of September and February

Quarterly Payments: 4 payments of $537.50 due on 1st of September, November, February, and May

Monthly Payments: 10 monthly payments of $215.00 due on 1st of September - June

Employees of SAU 39 Districts may participate in voluntary payroll deductions by obtaining the

payroll deduction form from SAU 39 Payroll Department. Copy of completed signed form must

accompany this registration.

A non-refundable $100.00 deposit must accompany this registration application and is

reflected in the payment plans above.

The first month’s tuition payment is due September 1st and is also non-refundable.

There is a 30 day notice requirement for withdrawal from this program. There will be no

refunds for withdrawal from the program after March 31.

______________________________________________ ______________________________________

Parent/Guardian Signature Date

Registration will not be considered complete unless deposit is received.

Please make checks payable to the Amherst School District.

AMHERST SCHOOL DISTRICT NEW STUDENT ENROLLMENT INFORMATION

Entry Date _________________ Student Homeroom Legal Name __________________________________________________ Sex ______ Grade ______ Teacher _______________________ Last First Complete Middle Name Mailing Address __________________________________________________________________________________________________________ Street Town State Zip code Home Address __________________________________________________________________________________________________________ (if different) Street Town State Zip code Date Place Of Birth ____/____/____ of Birth_________________________________ City State Ethnic Affiliation: _________ 01 – American Indian/Alaskan Native; 02 – Asian/Pacific Islander; 03 – Hispanic;

04 – Black, not of Hispanic Origin; 05 – White, not of Hispanic Origin (To fulfill state and national requirements for NH Register.)

PARENT/GUARDIAN INFORMATION

Home Home Parent 1 Name _____________________________________ Address ______________________________ Phone ___________________ Work Name/Address of Employer _____________________________________________________ phone/ext. ___________________________ Cell

Parent 1 e-mail address ________________________________________ Phone __________________________ Address Home Parent 2 Name ____________________________________ (if different) _____________________________ Phone __________________ Work Name/Address of Employer _____________________________________________________ phone/ext. ___________________________ Cell

Parent 2 e-mail address ________________________________________ Phone __________________________ Student lives with _________________________________________ Please indicate any language(s) other (Both parents/Father/Mother/Guardian/Specify other) than English spoken in the home. ___________________________

Should a copy of report card/progress report be mailed to non-custodial parent? _______ Name and Address of non-custodial parent (if not listed above)_________________________________________________________________________________

MEDICAL ALERT: (Condition/Allergy/Medication) _____________________________________________________________________________________

EMERGENCY INFORMATION

Emergency Contact (other than parent) Home Available 8:00-3:30 ______________________________________________________________________ Phone ____________________ Work Address ______________________________________________ Relationship ______________________ Phone ____________________ ______________________________________________________________________________________________________________

_____ I give permission for my child to participate in WALKING field trips in the town area. _____ I give permission for Clark/Wilkins School to post photographs of my child on the Clark/Wilkins website. _____ I give permission for Clark/Wilkins School to share photographs of my child with local newspapers. This is for the present school year 20_____- 20_____ . PLEASE SIGN BELOW. ________________________________________________ __________________________________________________________________________________ Date Parent/Guardian Signature

NEW STUDENT ENROLLMENT INFORMATION

ENTRY INFORMATION: AGE AT ENTRY _____________ HOW LONG HAVE YOU LIVED IN AMHERST? _______________________ PREVIOUS SCHOOL ATTENDED AND ADDRESS ______________________________________________________________________________ SIBLING NAMES AND BIRTH DATES: _________________________________________________________________________ _________________________________________________________________________ STUDENT PROGRAM INFORMATION PLEASE INDICATE IF YOUR CHILD HAS RECEIVED SUPPORTIVE SERVICES OR PARTICIPATED IN SUPPLEMENTAL PROGRAMS IN ADDITION TO HIS/HER REGULAR CLASS PROGRAM. YES ______ NO ______ IF SO, PLEASE DESCRIBE THE PROGRAM: ___________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ TEMPORARY HOUSING INFORMATION TEMPORARY ADDRESS __________________________________________________________________________________________ ________________________________________________________________TEMPORARY PHONE # _____________________ MOVE TO PERMANENT ADDRESS WILL BE COMPLETED ON __________________ CUSTODIAL AND RESIDENTIAL INFORMATION: Legal documents must be provided and will be attached. IS THERE ANY PERTINENT CUSTODIAL INFORMATION? NO _____ YES _____ IF YES, PLEASE SUMMARIZE: ____________________________________________________________________________________________________________________________________________________________________________________________ IS THERE ANY RESTRAINING ORDER INFORMATION? NO _____ YES _____ IF YES, PLEASE SUMMARIZE: ____________________________________________________________________________________________________________________________________________________________________________________________ ARE THERE ANY DISMISSAL RESTRICTIONS? NO _____ YES _____ IF YES, PLEASE SUMMARIZE: ____________________________________________________________________________________________________________________________________________________________________________________________ IS THERE A RESTRICTION ON SHARING INFORMATION WITH OTHER PARENT? NO _____ YES _____ IF YES, PLEASE SUMMARIZE: ____________________________________________________________________________________________________________________________________________________________________________________________ DOES THE CHILD RESIDE IN A HOUSE OTHER THAN YOUR OWN FOR ANY PART OF THE WEEK?

NO _____ YES _____ IF YES, PLEASE SUMMARIZE: ____________________________________________________________________________________________________________________________________________________________________________________________

NOTE TO PARENT/S or GUARDIAN/S: The licensing authority for this program is the Bureau of Licensing and Certification, Child Care Licensing Unit. Child care programs are required to post a copy of the statement of findings and corrective action plan for the most recent visit in a location which is accessible to parents, and must maintain copies of the statement of findings and corrective action plan for the preceding visit and make them available for parents to review upon request. Statements of findings and corrective action plans are also available on-line at http://childcaresearch.dhhs.nh.gov or by calling the unit at 1-800-852-3345, extension 4624 or 603-271-4624. During licensing, monitoring, and complaint investigation visits to licensed programs the department shall speak with children regarding the care they receive at the program, if in the judgment of the licensing coordinator the children’s response would be valuable in determining compliance with licensing rules. Licensing staff are experienced in working with children and trained to interview in a manner that is respectful and non-leading. However, if you do not want your child interviewed, or if you wish to be informed prior to your child being interviewed, you must give the family child care provider, center director, site director or designee, and update annually, a signed dated statement indicating your preference.

For more information about Child Care Licensing, please visit the website at: http://www.dhhs.state.nh.us/oos/cclu/index.htm

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Clark-Wilkins Preschool Information Form

Background Information Child’s Name_____________________________Birth Date___________ Nickname:________________________________Boy ____ Girl ____ Will your child be called by his/her nickname at school? Yes ____ No ____ Family Data: Type of Family Unit: (please circle) Two parent One parent Other

Maritial Status: (please circle) Single Separated Widowed Married Divorced

Home Address:

Email Address:

Home Phone:

Cell Phone:

Please List Siblings/Other Children in Household: Child’s Name:

Age:

Child’s Name:

Age:

Child’s Name:

Age:

Child’s Name:

Age:

Who will be responsible for the delivery & pick up of your child? Name Phone Number Relationship to your

Child

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Family Questionnaire

1. Has your child had any previous playgroup, preschool and/or childcare experiences?

2. Are there any special circumstances in the family that may be a factor in your child’s development, learning, and/or behavior?(e.g. divorce, new baby, illness, recent move, etc.)

3. How does your child relate to people outside the family?

4. What is your child’s favorite:

a. Toy______________________________________

b. Activity____________________________________

c. Book_____________________________________

5. What do you consider your child’s strengths?

6. Does your child have any particular fears (e.g animals, sirens, etc.)? If so, how do you respond to your child?

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7. In general, how does your child react to stressful/anxiety provoking experiences? Does he/she cry, withdraw, run, tantrum?

8. How do you reassure your child in stressful/anxiety provoking experiences?

9. In most circumstances, do you consider your child easily managed, fairly easy to manage or difficult to manage?

10. If and when circumstances arise, how do you discipline your child?

11. Is your child toilet trained for urine?

Is your child toilet trained for bowels?

12. What time is your child’s:

a. Bed time?

b. Nap time?

c. Quiet time?

13. What, if any are your concerns for your child?

14. What is important to you in your child’s preschool experience?

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15. In what ways would you like to see your child develop during his/her

Preschool year? Please add any additional comments you feel will help us know you and your child better: Parent Signature(s):______________________________________ Date:______________

Student Name: _______________________________________________ Grade: ________ Teacher: __________________________

Medications taken at home/school: _______________________________________________________________________________

Health Conditions, which may affect school activities: _______________________________________________________________

Medical Alert: _______________________________________________________________________________________________

Health Care Provider: ____________________________ Address: ______________________________ Phone: _________________

Dentist: _______________________________________ Address: ______________________________ Phone: _________________

Health Specialist: _______________________________ Address: ______________________________ Phone: _________________

Disclosure of Information By signing this section, I am giving the school nurse or principal my permission to disclose health information pertinent to the health and

safety of my child to staff who need to know. This is done with the understanding this information is to be considered and treated as

confidential by those who receive it.

Parent/Guardian Signature: _____________________________________________________________ Date: ________________

EMERGENCY TREATMENT AUTHORIZATION On rare occasions an emergency arises and we are unable to contact a parent/guardian, or emergency contact. In order that no delay may

occur that might jeopardize the life of a student, the school requests permission from the parent/guardian to seek emergency treatment.

I hereby grant permission to the SAU #39 School District to administer First Aid, secure proper medical treatment, and/or hospitalize my Son/Daughter/Ward: (student’s name): _________________________________________________________________________

In case of emergency, provided they are unable to communicate with me, and according to their best judgment, further delay may jeopardize the life or health of my (son/daughter/ward).

INSTRUCTIONS OR COMMENTS: ____________________________________________________________________________

Date: _____________________________ Parent/Guardian Signature: ________________________________________________

OVER THE COUNTER MEDICATION AUTHORIZATION AUTHORIZATIONS

The N.H. Board of Nursing requires parent’s written authorization for the school nurse to dispense any over-the-counter medication. The

following over-the-counter medications are available in the Health Office. If you want your child to receive any of these medications (per

package directions), please sign off on EACH medication. If you do not sign, we cannot dispense it.

I herby grant the SAU #39 staff to administer/assist my child (student name) ______________________________________________

In taking the following medications/topical treatments per package directions for weight/age. I understand the pain medications will only be

administered under circumstances for significant discomfort (headache, menstrual cramps, musculoskeletal pain) or fever. They would not be

administered for stomachache, pain from head injury, or in the event of potential internal injury. I certify, to the best of my knowledge, my

child has no allergy or sensitivity to and of the medications I am permitting the school nurse to dispense. Should my child develop any allergy

or sensitivity, I will notify the school immediately. I agree to hold harmless the SAU #39 school districts from any liability or responsibility

for and harmful effects that may occur as a result of my child taking the medications I have permitted.

Acetaminophen (generic Tylenol) for pain/fever: (parent/guardian signature): ______________________________________________

Bacitracin (antibiotic ointment) for wound care: (parent/guardian signature): ______________________________________________

Calamine Lotion for insect bites/itchy rashes: (parent/guardian signature): ______________________________________________

Diphenhydramine (generic Benadryl): (parent/guardian signature): ______________________________________________

for allergy symptoms: (there is a dose range Diphenhydramine – minimum dose will be given first unless otherwise specified)

Hydrogen Peroxide for wound care: (parent/guardian signature): ______________________________________________

Ibuprofen (generic Motrin) for pain/fever: (parent/guardian signature): ______________________________________________

AMHERST SCHOOL DISTRICT School Administrative Unit #39

Amherst, New Hampshire

CERTIFICATION OF ADDRESS Certification of the correct name and address of the student and parent or legal guardian is required to complete a school registration. A separate Certification of Address form is necessary for each student enrolled in Amherst Schools. Only students residing in Amherst (or Mont Vernon for 7th and 8th grade students) under the immediate supervision and custody of a parent or legal guardian may enroll without written permission from the Superintendent of Schools. Non-resident students, when admitted, will be expected to comply with all provisions of Board Policy JECB, Admission and Attendance of Non-Resident Students, including payment of tuition. Families planning to move into Amherst (or Mont Vernon for 7th and 8th grade students) and seeking to enroll children in Amherst schools must provide a certificate of occupancy permit, lease, or other evidence acceptable to the Superintendent of Schools to verify the date of occupancy. A pro-rated payment of tuition is expected; however, the Superintendent of Schools may waive tuition if the period of time between school enrollment and the establishment of residency is less than sixty (60) school days.

1. Full name of student: __________________________________________________________________________

2. Student residence:

a. Street and Number: _________________________________________________________________

b. Town: ________________________________________ State/Zip:__________________________

c. Telephone Number: ________________________________

3. Name and Address of legal:

Check one: Parent Guardian Court Assigned Custodian Court Emancipated Child Other, specify:

a. Name: ___________________________________________________________________________

b. Street and Number: _________________________________________________________________

c. Town: ____________________________________ State/Zip: _____________________________

d. Telephone Number: ________________________________

I understand that it is my obligation to promptly notify the school of any change in the above information. FURTHERMORE, I hereby certify under penalty of perjury that the above information is true and accurate. Signature of Legal Guardian: ______________________________________ Date: _____________________ Signature of Town Clerk: ________________________________________ Date: _____________________ Signature of Superintendent: ______________________________________ Date: _____________________

193.1 Duty of Parent: Compulsory Attendance by Pupil

I. A parent of any child at least 6 years of age and under 16 years of age shall cause such child to attend the public school to which the child is assigned in his resident district. Such child shall attend full time when such school is in session unless:

a) The child is attending a public school outside the district to which he is assigned or an approved private school for the same time;

b) The child is receiving home education; or c) The relevant school district superintendent has excused a child from attendance because the child is

physically or mentally unable to attend school, or has been temporarily excused upon the request of his parent for purposes agreed upon by the school authorities and the parent. Such excused absences shall not be permitted if they cause a serious adverse effect upon the student’s educational progress. Students excused for such temporary absences may be claimed as full-time pupils for purposes of calculating state aid under RSA 186-C:18 and RSA 198:27-33.

II. A child who reaches his sixth birthday after September 30 shall not be required to attend school under the provisions of this section until the following school year. III. In this section:

a) “Parent” means a parent, guardian, or person having legal custody of a child. b) “Resident district” means the school district in which the child resides.

IV. Any child at least 16 years of age and under 18 years of age who wishes to terminate such child’s public or nonpublic education prior to graduating from high school shall do so only after a conference with the principal, or designee. The principal shall request a conference with the parent, guardian, or other custodian. Written approval of withdrawal must be received from such child’s parent, guardian, or other person residing in the state and having custody or charge of such child at least 60 days prior to withdrawal. However, a waiver to the 60-day notice requirement may be granted at the discretion of the school board. The written approval shall be dated and the signature witnessed by the principal of the school where the child is in attendance, or the principal’s designee. SOURCE 1903, 13:1. 1911, 139.1. 1917, 52:1. 1919, 84.1. 1921, 85, III.1. PL118:1. RL137:1. 1949,92:1. 1953, 223:1. RSA 193:1.1985, 47:1. 1990, 279:1. 1994,

121:1 eff. Jan 1, 1995.

193:3 Change of School or Assignment; Excusing Attendance. I. Any person having custody of a child may apply to the school board for relief if he thinks the attendance of the child at the school to which such child has been assigned will result in a manifest educational hardship to the child. If the person having custody of the child is aggrieved by the decision of the school board of education, after investigating the case and giving notice to the school board, may order such child to attend another school in the same district, if such a school is available, or to attend school in another district. In case the child is assigned to attend school in another district, the district in which such child resides shall pay tuition computed as provided in RSA193:4 to the district in which such child attends. The state board of education may also permit such child to withdraw from school attendance for such time as it may deem necessary or proper or may make such other orders with respect to the attendance of such child at school as in its judgment the circumstances require. Educationally disabled children as defined in RSA 186-C:2 shall be accorded a due process review pursuant to rules adopted under RSA\186-C:16. II. The state board of education shall adopt rules pursuant to RSA\541-A, relative to manifest educational hardship and related issues which affect a child’s attendance at school. Each school district shall establish a policy, consistent with the state board’s rules, which shall allow a school board, with the recommendation of the superintendent, to take appropriate action including, but not limited to , assignment to a public school in another district when manifest educational hardship is shown. SOURCE 1871, 2:1. GL91:14. PS 93:14. 1901, 61:14. 1903, 13:1. 1911, 139.9. 1913, 22:1. 1919, 84:1. 1921, 85, III:3. PL 118:3 RL 137:3. 1949, 139:3. RSA 193:3. 1969, 356:2. 1973, 240:1. 1985, 48:1. 1990, 140:2,X. 1995, 98:1, eff. July 15, 1995. 193:12 Nonresidents. No person shall attend school, or send a pupil to the school, in any district of which he is not an inhabitant, without the consent of the district or of the school board except as herein otherwise provided. SOURCE RS 73:&. CS 77:7. GS 83:1. GL 91:1 PS 93:1. 1921, 85, III:9. PL 118:11. 1927, 58:1. RL 137:11. RSA 193:12. 1955, 227:2, 263:1, eff. July 1, 1956