Walker / REGISTRATION FORM / School
Student Information
Student Last Name / First Name / Middle Name / DOB
MM/DD/YYYY / Gender
M F / Grade Entry
Student’s Primary Dwellingand Legal Parents/Guardians
Check each legal parent/guardian with whom thestudent lives. If shared, check each that apply. NOTE: Legal documentation-see section below.
[ ] LegalParent/Guardian #1 / DOB
MM/DD/YYYY / Relationship / Street Address, Town, State, Zip / Primary Phone
( ) --- / Other Phone
( ) ---
Email: / Mailing Address
[ ] Indicate Branch of Military if on Active Duty (for either or both parents/guardians)
[ ] Legal Parent/Guardian #2 / DOB
MM/DD/YYYY / Relationship / Street Address, City, Town, Zip / Primary Phone
( ) --- / Other Phone
( ) ---
Email: / Mailing Address
[ ] Indicate Branch of Military if on Active Duty (for either or both parents/guardians)
Legal Parent with Whom the Child Does NOT Live
(*Attach legal documents to this form.)
Is there a custodial agreement in place? None Joint Sole / Is there a restraining order? No Yes Expiration Date
Parent / DOB
MM/DD/YYYY / Relationship / Street Address / *Legal Documents Received On:______
*Office Staff Initials:
Email: / Town,State,Zip
Other Children Living In Home
(Please list all other children living in the home with the student. Use reverse side if necessary.)
Last Name / First Name / Middle Name / DOB / Grade / School
MM/DD/YYYY
MM/DD/YYYY
MM/DD/YYYY
MM/DD/YYYY
Emergency Contacts
IMPORTANT:List individuals other thanthe legal parents/guardians listed above. ONLY these individuals will be authorized to accept responsibility,be notified
of illness/emergency or be granted the right to pick up student from school.
Name / Primary# / Other# / Relationship
Name / Primary# / Other# / Relationship
Name / Primary# / Other# / Relationship
Name / Primary# / Other# / Relationship
IMPORTANT: Chariho will utilize One Call Now in the event of early closing of schools. In the event that no one is at home, my child has been instructed to follow this contingency plan:
Medical Information
Medical Problems
Medications / / Given Daily / / Given as Needed
Authorization for School Nurse to Administer /
Cough Drops /
Acetaminophen
(Tylenol) / Ibuprofen
(Advil) /
Tums / Doses appropriate for age and weight
Local Physician’s Name / Address / Office Phone
( ) ---
I give authorization for RN to contact physician.
Signature of Legal Parent/Guardian.
YOUR SIGNATURE IS REQUIRED / Date
It is your responsibility to keep the school advised of any changes.
Student Information
Student Last Name / First Name / Middle Name / DOB
MM/DD/YYYY / Gender
M F / Grade Entry
Race/Ethnicity Data
State of RI Format Part A - Federal Part B - Federal
Check ONE Only: / Check ONE: / Check ONE or MORE
[ ] Native American / Is this student (or are you) Hispanic/Latino? / What is the student’s (or your) race?
[ ] Asian/Pacific Islander / [ ] No, not Hispanic/Latino / [ ] American Indian or Alaska Native
[ ] Black (Not Hispanic) / [ ] Yes, Hispanic/Latino / [ ] Asian
[ ] Hispanic / [ ] Black or African American
[ ] White (Not Hispanic) / [ ] Native Hawaiian or Other Pacific Islander
[ ] White
Other Important Information / Does/Did your child have:
[ ] An IEP / [ ] A 504 Plan / [ ] Other Remedial Services / [ ] ESL Services
Home Language Survey
Is there a language, other than English, spoken in your home?
- Did your child learn to speak English first?
- Did/does your child spend time with grandparents, relatives or friends whom speak another language?
- If you answered yes to any of these questions, with which other language has your child been familiar?
- Has your child ever been enrolled in ESL services?
- If yes, which program was used?
Rev. 10/2017-dvfitzgerald