Elementary Student Enrollment Form

Student Name *

Home Address *

Mailing Address *

County *

Gender *

Male Female

Grade Level *

If New, Where Did You Last Attend School?

The Following Questions Are Requried Information We Must Have.

What is Your Ethnicity? *

What is Your Race? *

Language Most Frequently Spoken at Home? *

Language Your Child First Used When Learning How To Talk *

Language Your Child Most Frequently Speaks at Home? *

Language You Most Frequently Use When Speaking To Your Child *

Home Phone Number *

Moms' Work Number

Mom's Cell Number

Dad's Work Number

Dad's Cell Number

Mom's Email Address

Dad's Email Address

In Case of Emergency, and above numbers cannot be reached, please give an emergency name and phone number to contact.

Emergency Contact Name *

Emergency Contact Number *

Family Doctor Information

Phone Number of Doctor

Any Pertinent Information abut child the we should know about? Examples such as allergies, Eye problems. *

DO WE HAVE YOUR CHILD'S IM,IMMUNIZATION RECORD? *

DO WE HAVE YOUR CHILD'S BIRTH CERTIFICATE?

OUT OF TOWN BUS STUDENTS ONLY

EMERGENCY IN TOWN SHELTER

PLEASE REMIND THIS PERSON THAT THIS INFORMATION IS BEING PROVIDED TO THE SCHOOL

NAME

PHONE NUMBER

ADDRESS