Richland School District Enrollment Form Orchard Elementary School

Administration Office – 615 Snow Ave Richland, WA 99352 1600 Gala Way Richland, WA 99354

Today’s Date _____/_____/_____ Have you withdrawn from the previous school (circle one) YES NO

Has this child attended a Richland School in the past? (circle one) YES NO If yes, name of RSD School______Approximate date student withdrew from last RSD school_____/_____/_____

Student’s Legal Last Name: / Student’s Legal First Name: / Student’s Middle Name:
Birth date: _____/_____/_____ / Student # (Office will assign): / Grade:
Does this child have school records by any other name? If so, please list all:
“Goes by” Last Name (If different than Legal Name): / “Goes by” First Name (If different than Legal Name): / Date student will start school:
_____/_____/_____
Parent/Guardian (Format: John & Jane Smith):
Residence Address: / City: / State: / Zip:
Mailing Address: / City: / State: / Zip:
Parent/Guardian 1 E-mail Address: / Parent/Guardian 2 E-mail Address:
Home Phone # / Is this # unlisted? YES NO / Restrict Directory Information? YES NO
Gender (circle one)
Male Female / Birth Country (If born outside of USA) / Date Enrolled in U.S. Public School (If born outside of USA)
_____/_____/_____
Ethnicity: Is your child of Hispanic or Latino origin? NO YES (circle all that apply)
Cuban
Dominican / Spaniard
Puerto Rican / Mexican/Mexican American/Chicano
Central American / South American
Latin American / Other Hispanic/Latino
What race do you consider your child? (Circle all that apply)
African American or Black
White or Caucasian
Asian Indian
Cambodian
Chinese
Filipino
Hmong
Indonesian
Japanese
Korean
Laotian / Malaysian
Pakistani
Singaporean
Taiwanese
Thai
Vietnamese
Other Asian
Native Hawaiian
Fijian
Guamanian or Chamorro
Mariana Islander / Melanesian
Micronesian
Samoan
Tongan
Other Pacific Islander
Alaska Native
Chehalis
Colville
Cowlitz
HOH
Jamestown / Lower Elwha
Lummi
Makah
Muckleshoot
Nisqually
Nooksack
Port Gamble Klallam
Puyallup
Quileute
Quinault
Samish / Sauk-Suiattle
Shoalwater
Skokomish
Snoqualmie
Spokane
Squaxin Island
Stillaguamish
Suquamish
Swinomish
Tulalip
Yakama / OTHER:
Washington Indian
American Indian
Student’s primary language (If other than English): / Language spoken at home (If other than English):
PARENT / GUARDIAN INFORMATION
Parent/Guardian 1 Information
Parent/Guardian 1 Last Name: / Parent/Guardian 1 First Name:
Parent/Guardian 1 Street Address (if different than student):
City: / State: / Zip: / Parent/Guardian 1 Home Phone #:
Parent/Guardian 1 Cell Phone #: / Parent/Guardian 1 Daytime Phone #:
Parent/Guardian 1 Employer: / Parent/Guardian 1 Work phone #:
Does student live with Parent/Guardian 1? YES NO / If NO would you like extra mailing sent to Parent1? YES NO
Is there a NO CONTACT order for Parent/Guardian 1? YES NO
Parent/Guardian 2 Information
Parent/Guardian 2 Last Name: / Parent/Guardian 2 First Name:
Parent/Guardian 2 Street Address (if different than student):
City: / State: / Zip: / Parent/Guardian 2 Home Phone #:
Parent/Guardian 2 Cell Phone #: / Parent/Guardian 2 Daytime Phone #:
Parent/Guardian 2 Employer: / Parent/Guardian 2 Work Phone #:
Does student live with Parent/Guardian 2? YES NO / If NO would you like extra mailing sent to Parent2? YES NO
Is there a NO CONTACT order for Parent/Guardian 2? YES NO
ADDITIONAL PARENT / GUARDIAN INFORMATION
Parent #3 Relationship (circle one): Stepfather Stepmother Foster /Legal Guardian Grandparent Other______
Parent Last Name: / Parent First Name:
Residence Address: / City: / State: / Zip:
Home Phone #: / Cell Phone #: / Day Phone #:
Employer: / Work Phone #:
Does the student reside with this parent? YES NO / NO CONTACT order with this parent? YES NO
Parent #4 Relationship (circle one): Stepfather Stepmother Foster /Legal Guardian Grandparent Other______
Parent Last Name: / Parent First Name:
Residence Address: / City: / State: / Zip:
Home Phone #: / Cell Phone #: / Day Phone #:
Employer: / Work Phone #:
Does the student reside with this parent? YES NO / NO CONTACT order with this parent? YES NO
EMERGENCY CONTACT INFORMATION
IMPORTANT – Please list emergency contact information OTHER THAN PARENTS in the order you wish to have them called.
CONTACT #1
Contact Last Name: / Contact First Name:
Relationship:
Phone #: / Phone # is: HOME WORK CELL
CONTACT #2
Contact Last Name: / Contact First Name:
Relationship:
Phone #: / Phone # is: HOME WORK CELL
CONTACT #3
Contact Last Name: / Contact First Name:
Relationship:
Phone #: / Phone # is: HOME WORK CELL
ADDITIONAL INFORMATION
Attendance Issues: Does your child have a Becca Bill Petition? NO YES If yes, from what county ?______
Suspension: Has your child been suspended for more than 10 days in the past calendar year? If so, for what? ______
Expulsion: Is your child currently expelled from another school district? NO YES If yes, attach a separate page to explain the circumstances.
Circle previous / current participation in: (all that apply) Gifted Title 1 ESL Math or Reading Assistance OT Services Speech Special Education (IEP) 504 Plan
Describe any physical limitations or health problems your child has (circle all that apply to your child):
Asthma Diabetes Heart Condition Seizures/Epilepsy Allergies: Bee Stings or Food
Other (Please Explain):__________________
Primary Care Physician:______
Is medication given for any reason? ___ AT HOME ___ AT SCHOOL - (medical authorization form required for medication at school)
NAME AND ADDRESS OF PREVIOUS SCHOOL
School: / Grade:
Address: / City: / State: / Zip:
Phone #: / Fax #:
Date of withdrawal _____/_____/_____ / Reason for withdrawal:
SIBLING INFORMATION
Name: / School: / Grade: / Birth date: Age:
Name: / School: / Grade: / Birth date: Age:
Name: / School: / Grade: / Birth date: Age:
Name: / School: / Grade: / Birth date: Age:

Parent/Guardian Signature:

Checklist for Enrollment
Sent for Records on: / Records received:
Parent Portal information given to parent: / Student Passwords given to student:
Bus route given to student: / Locker Assignment: / Combo:
MAP: / Proof of residency: