PEEP Assessment Permission Form

Pre Entry and Exit Profile (PEEP) for Preschoolers

* Confidential *

As you are aware we conduct PEEP assessments in our preschool program. This assessment is something that tracks the development of the children. In order for our program to be included in the collection of data showing that children are being prepared to enter into kindergarten, the state board of education collects the information by assigning an Statewide Student Identifier (SSID) to each student. The SSID number follows the child throughout elementary school and beyond. This gives other teachers opportunities to expand upon the current knowledge and development. We need your help as families to fill out the proper information so that we can register the SSID. For further information, please visit the state board of education website at: State Board of Education (PEEP Assessment)

Child's Name:(Required)

First Middle Last

Child's Gender:(Required)

Male

Female

Child’s Birth Date:(Required)

Child’s Age as of 09/01/2020(Required)

Birth Certificate Number:(Required)

Parent 1 First Name:(Required)

Parent 2 First Name:(Required)

Home Language(Required)

Consent(Required)

I agree to these terms. I agree to these terms. I give consent to A to Z Building Blocks to share my child's PEEP assessment with the Utah State Board of Education.(Required)

Signature

Upload Birth Certificate

Max. file size: 300 MB.

Thank you for taking the time to complete this form and allowing us to provide a great preschool program for your child.

Draper

Spanish Fork

* Confidential *

AMERICAN FORK

OREM

EAGLE MOUNTAIN

DRAPER

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