Student Registration Form

Student Registration Form

School Year 

Basic Student Information - Part 1

 

Last Name  First Name  Middle  Other 

Sex Male  Female  Date of Birth  Age  Birthplace 

School  Grade  Social Security Number 

Transferred From  Address: 

NOT born in any State*

Has NOT been attending one or more schools in any one or more states* for more than 3 full academic years.

If NO, how many years at the point of enrollment 

*State refers to the 50 U.S. States, the District of Columbia, and the Commonwealth of Puerto Rico)

Home School: 

Grade Level: 

911 Address 

City  State/Zip 

Mailing Address 

City  State/Zip 

Student Home Phone #  Listed  Unlisted  

Transport by Bus:  If YES, Bus #  AM  PM  Special Medical Need 

List Siblings 

Is home language English   Native Language 

Hispanic   Race Options (Check all that apply) 

 

Parent/Guardian Information - Part 2

Call Order 

Last Name  First Name  Middle  Relationship 

Home Phone #  Cell Phone # 

911 Address 

City  State/Zip: 

Mailing Address if different than above 

City  State/Zip 

Employer Name: 

Employer Work Phone#   Ext. 

Occupation  Cell Phone #  Ext

Pager #  Ext.  Email Address 

I require translator services to communicate

 

Parent/Guardian Information - Part 3

Call Order 

Last Name  First Name  Middle  Relationship 

Home Phone #  Cell Phone # 

911 Address 

City  State/Zip: 

Mailing Address if different than above 

City  State/Zip 

Employer Work Phone#   Ext. 

Occupation  Cell Phone #  Ext

Pager #  Ext.  Email Address 

I require translator services to communicate

 

Emergency Contact Information Other than Parent/Guardian for Immediate Pick-Up from School - Part 4

Call Order 

 

Last Name  First Name  Middle  Relationship 

Home Phone #  Cell Phone # 

911 Address 

City  State/Zip: 

Mailing Address if different than above 

City  State/Zip 

Employer Work Phone#   Ext. 

Occupation  Cell Phone #  Ext

Pager #  Ext.  Email Address 

I require translator services to communicate

CALL ORDER INDICATES THE ORDER IN WHICH TO CONTACT PARENTS/GUARDIANS IN THE EVENT OF AN EMERGENCY

The questionnaire in this section is intended to address the McKinney-Vento Act 42 U.S.C. 11435. The answers to this residency information will help determine services the student may be eligible to receive.

1. Is your current address a temporary living arrangement? 

2. If YES, is this temporary living arrangement due to loss of housing or economic hardship? 

Signature of Parent/Guardian  Date 

By checking this box, I verify my identity and that the information was entered accurately

 

 

Student  School 

In case the child for whom I am responsible becomes seriously ill or injured at school, please take them to . The physician and hospital are hereby authorized to render such treatment as may be deemed necessary in an emergency for the health of this child.

 

Home Phone #  Work Phone #  Cell Phone #  Pager #  Email Address 

Name of Physician   Physician Phone # 

Physician's Address 

Check the box next to any conditions the above student has:

1. Heart Defect                    

2. Diabetes                        

3. Convulsions/Seizure Disorder      

4. Cerebral Palsy                  

5. Visual Impairment               

   a. Corrective Glasses            

6. Hearing Impairment              

   a. Hearing Aid                  

8 Orthopedic Impairment            

   a. Wears Prosthesis             

9. Scoliosis                      

10, Behavioral Disorders            

12. Gastro/Intestinal Disorder        

11. Asthma                       

14. Allergies                      

   a. Seasonal                    

   b. Food                       

   c. Bee Sting                    

15. Nasal/Respiratory Disorder       

16. Limited Activities                

17 Premature Birth                 

18. Other                         

 

Signature Parent or Guardian   Date 

By checking this box, I verify my identity and that the information was entered accurately

I AM 18 YEAR OF AGE OR WILL BE 18 YEARS OF AGE DURING THE SCHOOL YEAR AND HEREBY GRANT MY CONSENT FOR JEFFERSON COUNTY SCHOOLS TO CONTACT ANY LEGAL GUARDIAN IN CASE OF EMERGENCY

Student's Signature:  Date 

By checking this box, I verify my identity and that the information was entered accurately



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