Student Information
     

Last Name _________________________ Legal First Name ____________________________

 

Middle Name ________________ Prefers to be Called _______________________Male/Female

                                                                                                                                    (Circle one)

Address ______________________________  City ____________________ Zip ___________

 
Home Phone ____________________ Birth Date _________________ Grade Level __________
   

Parent Information
   
Father _____________________ Work Place _______________  Work Phone ______________

Address__________________________City_______________Zip________Cell_____________

(if different than student's address)

Mother ____________________ Work Place ________________ Work Phone ______________

Address__________________________City_______________Zip________Cell_____________

(if different than student's address)
   
Student lives with  _______________________________________________________________

Legal/Court/Custody Information ____________________________________________________

(attach appropriate copies)
    

Emergency Information
Other than Parents:

Emergency Contact #1-Name _________________________ Phone ____________Cell________

 

Emergency Contact #2- Name _________________________ Phone ___________Cell_________

 

Physician Name _______________________________ Physician Phone ____________________

 

Medical Alert Information _________________________________________________________

 

Emergency Dismissal Plan _________________________________________________________

(where your child should go if there is an unscheduled early dismissal)
    

Miscellaneous
Is a language other than English spoken in daily interaction in the student's home?_________________
Does the student speak a language other than English?_____________________________________

Special Needs
     

Has child been enrolled in any special education classes or OT/PT/speech?   Yes/No (please circle one)

 

If Yes, please list which services_____________________________________________________

 

Would you like to apply for free or reduced lunches?   Yes/No (please circle one)
   

__________________________________________________

Parent/Guardian Signature

_________________________

Date
    
        _______________________________________________________________________    

For Office Use Only
Student ID# ________ Date Enrolled __________ Lunch # ___________ Bus # _________ Homeroom ________