North College Hill Middle School

NORTH COLLEGE HILL MIDDLE SCHOOL

STUDENT ENROLLMENT FORM

2017/2018

STUDENT INFORMATION PLEASE PRINT DATE_______

Name______Grade______

LastFirst Middle

Sex:Male Female Birth Date______

Address______Zip Code______Home Telephone #__________

Place of Birth______Social Security #______

City State (For Foster Students Only)

Is the above student Hispanic/Latino?___yes___no___ (Hispanic or Latino means a person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin regardless of race)

Ethnic Code(s): Choose ALL that apply

_____ American Indian or Alaskan Native_____Black or African American _____Asian

_____ Native Hawaiian or Other Pacific Islander _____White (Non-Hispanic)

(Please be aware that when the parent or guardian refuses to provide their child’s racial group, the district shall use observer identification. This designation is required to be communicated to the parent or guardian by the district prior to designation.)

PREVIOUS SCHOOL INFORMATION

(Preschool/Headstart Program Information must be included for new Kindergarten students, only).

Preschool______Dates attended ______

Head Start Program ______Dates attended ______

Last School Attended ______School District______

School Address______Last Home Address______

Are fees paid and records available from your student’s previous school?Yes____No____

Is the student currently suspended?Yes____No____

Is the student currently expelled?Yes____No____

Has the student attended school in NCH City Schools before?Yes____No____

If the student has been in Special Education, please state the program______

Does the student have a current Special Education IEP?Yes____No____

PARENT or GUARDIAN INFORMATION

Father’s Name______Cell Phone # ______

Address______Home Phone #______

Place of Employment______Work Phone#______

Father’s E-mail address______

Mother’s Name______Cell Phone # ______

Address______Home Phone #______

Place of Employment______Work Phone#______

Mother’s E-mail address______

Step Parent’s Name______Cell Phone #______

Address______Home Phone #______

Place of Employment ______Work Phone #______

Step Parent’s E-mail address______

Parents Married?YesNoSeparated?YesNoDivorced?YesNoDeceased? YesNo

Parent with Legal Custody?MotherFather

Legal Guardian’s Name ______Cell Phone #______

Address ______Home Phone #______

Place of Employment ______Work Phone#______

Court Placement?YESNOFoster Home?YESNOHas Legal Custody?YESNO

Address where parent(s) lived when custody was transferred:

Street Address______City/State/Zip ______

BROTHERS/SISTERS

Name Age Grade/School

______

______

In case of emergency, persons to notify if parent/guardian cannot be contacted. In addition to parents/guardians, only the persons listed below will be permitted to sign your student out of school during school hours.

Contact #1 (Other than Parent/Guardian):

______

Name Address

______

Phone # Cell Phone# Relationship

Contact #2 (Other than Parent/Guardian):

______

Name Address

______

Phone # Cell Phone# Relationship

I have read this registration form completely and certify the statements included are true and current.

______

PARENT/GUARDIAN SIGNATURE DATE

FALSIFICATON OF INFORMATION MAY RESULT IN ACTION TO RECOVER EDUCATIONAL COST TO NORTH COLLEGE HILL CITY SCHOOLS PRORATED ACCORDING TO THE CURRENT DISTRICT TUITION RATE.