Special Education Services/Programs Please specify: Speech RSP Has the student ever participated Title I Math ESL 504/IEP in any Special Education services Yes No or programs? Title I Reading Other Ethnicity Are you Latino or Hispanic? Yes No Race mark all that apply – Caucasian or African American Native Hawaiian / Other Pacific Islander (not of Hispanic American Indian or Alaska Native origin) Asian Home Language (Please mark the language used most often at home) English Spanish Other _____________________________________ Other Pertinent Information How did you hear about Regina? Was there a member of the Regina community If yes, please list that person’s name (one name only, please) who was instrumental in helping you to make Yes No the decision to send your student to Regina? Does your student have any special If yes, please list the concerns medical / health / dietary concerns about which Yes No we should know? Please add anything else that you think is important to help us know your student better (interests, etc.). Parent Signature: __________________________________________ Date: ________________ A $172 application fee* is required to be submitted with Additional information is required before the start of this form. the school year: *Fee includes $100 registration fee, $60 milk fee and $12 nap mat fee. Birth Certificate Immunization Record Parish Registration Form Dental Screening Form Please submit this application and fee to: Regina Elementary School Celeste Vincent, Principal Kelly Starr, Vice Principal 2120 Rochester Ave celeste.vincent@regina.org kelly.starr@regina.org Iowa City, IA 52245 Office: 319.337.5739 Office: 319.337.5739 Fax: 319.338.2443 Fax: 319.338.2443 For Office Use Only Entry Date into District: Regina Student ID #: State ID #: Date Submitted: Application Fee Included:
Special Education Services/Programs Has the student ever participated in any Special Education services or programs? Yes No Please specify: Speech RSP Title I Math ESL 504/IEP Title I Reading Other Ethnicity Are you Latino or Hispanic? Yes No Race – mark all that apply Caucasian (not of Hispanic origin) Asian or African American American Indian or Alaska Native Native Hawaiian / Other Pacific Islander Home Language (Please mark the language used most often at home) English Spanish Other _____________________________________ Other Pertinent Information How did you hear about Regina? Was there a member of the Regina community who was instrumental in helping you to make the decision to send your student to Regina? Yes No If yes, please list that person’s name (one name only, please) Does your student have any special medical / health / dietary concerns about which we should know? Yes No If yes, please list the concerns Please add anything else that you think is important to help us know your student better (interests, etc.). Parent Signature: __________________________________________ Date: ________________ A $172 application fee* is required to be submitted with this form. *Fee includes $100 registration fee, $60 milk fee and $12 nap mat fee. Additional information is required before the start of the school year: Birth Certificate Immunization Record Parish Registration Form Dental Screening Form Please submit this application and fee to: Regina Elementary School 2120 Rochester Ave Iowa City, IA 52245 Celeste Vincent, Principal celeste.vincent@regina.org Office: 319.337.5739 Fax: 319.338.2443 Kelly Starr, Vice Principal kelly.starr@regina.org Office: 319.337.5739 Fax: 319.338.2443 For Office Use Only Entry Date into District: Regina Student ID #: State ID #: Date Submitted: Application Fee Included:
Regina-Kindergarten-Application.docx