ELIMU LEARNING CENTER REGISTRATION FORM

ELIMU LEARNING CENTER

Student Data Sheet
STUDENT CURRENT SCHOOL
Student Name

First NameLast Name
Date

MonthDayYear
Grade
Mother/Gaurdian

First NameLast Name
Father/Gaurdian

First NameLast Name
Email
example@example.com
Parents Country of Origin
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for Referral
Academic Area

MathematicsReadingOther
Behavior

Complete Social/Emotional Worksheet
Birth Date

MonthDayYear
Special Needs
Discipline Record
Number of discipline reports
Number of total suspensions
Number of inschool suspensions
Number of out of school suspensions
Most Recent Academic Grades

Letter Grade
Grades

English/Language Arts

Reading

Math

Spelling

Science

Social Studies

Health/PE

Other

Total: 0/ A-F
Retentions
Year(s)
Grade(s)
Click to edit
Previous enrollment in Special Education Programs/Section 504
MINOR (CHILD) PHOTO RELEASE FORM

I parent or legal guardian of the child above I grant Elimu Empowerment Services my permission to use the photographs for any legal use, including but not limited to: publicity, copyright purposes, illustration, advertising, and web content.

Furthermore, I understand that no royalty, fee or other compensation shall become payable to me by reason of such use.
Parent Signature(Full name)
Should be Empty:

ELIMU LEARNING CENTER