DillonSchool DistrictFour Registration Form

Are you a transfer student? ____Yes____No (If yes, please complete “Request for Student Records”)
Transfer InformationLastSchool Attended: ______
Address: ______
(Street/P.O. Box # City State Zip
______
Telephone Number Fax Number
Have you ever attended a DillonSchool District Four school? _____
If so, what was the last school? ______

Student’s Name______

Last Gen(Jr., III, etc.)FirstMiddle

______

Nickname Home Phone(XXX-XXX-XXXX)

______

Home Address(911 Address)HomeCity, State, Zip

Mailing Contact Name______

______

Mailing Address(If different from 911 Address)MailingCity, State, Zip

Sibling Information (include all siblings from birth to 18)
Name / Age / Sex / School / Grade

Gender ____M ____F ______

DOB (mm/dd/yyyy)Social Security Number

(Requested for student identification purposes not required)

Ethnicity/Race: Are you Hispanic/Latino ____Yes ____No
What race or races are you? ____American Indian or Alaska Native ____Asian ____Black or African American ____Native Hawaiian or Other Pacific Islander ____White
Foster Home ____Yes ____NoFoster Home School District ______
Homeless ____Yes ____NoMigrant ____Yes ____No ______
Medicaid Number
Transportation Needed ____Yes ____No
____Car Rider ____Daycare Provider ____Walker ____Bicycle

Does your child receive any of the following?

____ESOL ____Gifted and Talented ____Speech/Special Education ____504 Plan

______

Mother’s Name (Last Name, First Name)Mother’s Day Phone

______

Mother’s Home PhoneMother’s Cell Phone

Mother’s Employer ______Mother’s Email ______

Resides With Mom ____Yes ____No Mom Has Custody ____Yes ____No

______

Father’s Name (Last Name, First Name)Father’s Day Phone

______

Father’s Home PhoneFather’s Cell Phone

Father’s Employer ______Father’s Email ______

Resides With Dad ____Yes ____No Dad Has Custody ____Yes ____No

______

Guardian’s Name (Last, First, Middle)Guardian’s Day Phone

______

Guardian’s Home PhoneGuardian’s Cell Phone

Guardian’s Employer ______Guardian’s Email ______

Resides With Guardian ____Yes ____NoGuardian Has Custody ____Yes ____No

Foster Parent ____Yes ____No

______

Foster Parent’s Name (Last Name, First Name)Foster Parent’s Day Phone

______

Foster Parent’s Home PhoneFoster Parent’sCell Phone

Foster Parent’s Employer______Foster Parent’s Email______

______

Emergency Contact #1 – Mother (Last Name, First Name)

______

Home PhoneWork Phone

______

Cell PhoneEmail

Receive Mailings _____Yes _____NoHas Custody _____Yes _____No

______

Emergency Contact #2 – Father (Last Name, First Name)

______

Home PhoneWork Phone

______

Cell PhoneEmail

Receive Mailings _____Yes _____NoHas Custody _____Yes _____No

______

Emergency Contact #3 – Guardian (Last Name, First Name)

______

Home PhoneWork Phone

______

Cell PhoneEmail

Receive Mailings _____Yes _____NoHas Custody _____Yes _____No

______

Emergency Contact #4 (Last Name, First Name)Relationship

______

Home PhoneWork Phone

______

Cell PhoneEmail

Receive Mailings _____Yes _____NoHas Custody _____Yes _____No

______

Emergency Contact #5 (Last Name, First Name)Relationship

______

Home PhoneWork Phone

______

Cell PhoneEmail

Receive Mailings _____Yes _____NoHas Custody _____Yes _____No

______

Name of DaycareDaycare PhoneDaycare Contact

Directions to Home(Required For 4K and 5K)

______

______

______

This Form Completed By:

______

Name Relationship Date

Revised 10/4/2012

Office Use Only:S.C. Immunization Certificate on file? ____ Date Expires: ______(date or n/a)

Reviewed by RN: ______(date) ______(RN initials)

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Health Information for Nursing Staff

(Parent must complete)

Demographics:

Student: ______DOB: ______Grade: ______

Medical Information: (Parent MUST provide medical documentation)

Medical Doctor: ______

Does student have any health concern/problem: Yes No (please circle)

Health Concern(s)/Problem(s): Please specify: ______

(Please request a medical release form- “Disclosure of Protected HealthInformation”)

DillonSchool District Four recommends that parents administer all medications to students at home. In the event that any medicine is required during school hours, medication form(s) must be completed &returned to the school nurse. Student may be assisted by school personnel as designated by the principal, since the schools do not have a nurse present on campus at all times.

My child requires the following medication during school hours-(mark all that apply)

_____ Epi-pen (for severe allergies)

______inhaler

______medicine by mouth (Name of medicine(s) ______)

______other

Diet Restrictions: Yes No (please circle) (If yes, please request diet prescription form)

The school is not required to provide substitutions for an allergy or food intolerance, and is permitted to do so ONLY when omitted foods and appropriate substitutions are specified by a medical authority. If diet modifications are implemented by the school, they will continue until a medical authority specifies that they should be changed or stopped. Parents/guardians are asked to annually request updated instructions for diet modifications from a medical authority.

Special needs/requirements: (requires written orders by MD)

(Catheterization, physical restrictions/limitations, other)

Please specify: ______

Medical forms can be found on our website

Medication (prescription & non-prescription)

Diet Forms (requires MD to complete)

Medical Release Forms “Disclosure of Protected Health Information”

Parent signature: ______Date: ______

Revised 10/4/2012

Office Use Only

Enrollment Date ______Grade ______Homeroom ______

Check When Completed/Presented:

____Birth Certificate

____Permanent Resident Card (if applicable)

____Social Security Card

____South Carolina Immunization Record

____Proof of Residence

____Lunch Form (send to Food Service)

____Case Number from Department of Social Services (if applicable)

____Internet Use Policy/FERPA/Video Release/Textbook/ID Badge

____Medicaid Number from Department of Social Services (if applicable)

____Medicaid Permission to Bill (give to nurse)

____Authorization for Release of Information (give to nurse)

____Comprehensive Health Law (send to student’s grades 6-12)

____Custody Restrictions

____Home Language Survey (if language other than English, send to ESOL contact)

____Biometric Release

____Affidavit (if applicable)

____Discipline Code Book (grades K-12)

____Policy JICJ Possession/Use of Electronic Communication Devices in School

____Gifted & Talented (contact the appropriate office)

____Speech, Special Education (IEP), 504 Plan (contact the appropriate office)

____Circle Parent’s Choice of Primary Race Code for Federal Reporting

American Indian or Alaska Native

Asian

Black or African American

Hispanic/Latino

Native Hawaiian or Other Pacific Islander

Two or More Races

White

Revised 10/4/2012

1/3/20191