Robertson County Public Schools 2014 – 2015 School Year

Student Enrollment Form (Please print use a pen)

Date ______

Student Information__Please Print______

Student’s Full Legal Name ______

LastFirstMiddle (Full)

Gender M FBirthdate ___/___/______State of Birth ______Country of Birth ______

Ex: 02/02/2002

Grade ______Student SS# ______Home Phone _(____)______

Cell # _(___)______

Ethnicity______

 White (Not of Hispanic Origin)  Black (Not of Hispanic Origin) Hispanic

 American Indian or Alaskan Native  Asian or Pacific Islander Other______

Residence Address ______Apt# _____ City ______State ____ Zip ______-___

Mailing Address (If different) ______Apt#_____ City ______State ____ Zip ______-____

Parent/Guardian may be asked to provide proof of residency (deed, mortgage receipt, rent receipt, rental agreement, utility bill, etc.) at the time of enrollment.

Transportation: Student will Ride Bus twice daily Ride Bus once daily  a.m.  p.m.  Will not ride the bus

 Drive to school

Parent/Guardian Information(These Primary Guardians are the ones with whom the student(s) lives)______

Female Guardian Name ______Relationship to student ______

LastFirstMiddle (Full)

Employer Name:______Work Phone (____)______Military? Y N

Cell Phone (____)______Email______@______

Educational Level:(Highest completed: check grade & degree) 8 9 10 11 12(high school graduate) 13 14 Associate Degree

15 16 Bachelors Degree Graduate Degree

Email______@______Does parent have Internet access Yes No

______

Male Guardian Name ______Relationship to student ______

LastFirstMiddle (Full)

Employer Name:______Work Phone (____)______Military? Y N

Cell Phone (____)______Email______@______

Educational Level:(Highest completed: check grade & degree) 8 9 10 11 12(high school graduate) 13 14 Associate Degree

15 16 Bachelors Degree Graduate Degree

Other Parent/Guardian Information (Shared parenting responsibility: Second mailing information)

Name ______Relationship to student ______

LastFirstMiddle (Full)

Mailing Address ______Apt# _____ City ______State ______Zip ______-_____

Household Telephone ___(_____)______Cell Phone _(____)______Work Phone _(____)______

Other Children Under Age 18 Living in the Home (include all children regardless of age)

First Name / Middle (Full) / Last Name / Birthdate / Gender / Relation to Student / School Attending

Emergency Contact Information_(other than parent/guardian)______

Name ______Relationship to student ______

Home Phone (____)______Work Phone (____)______Cell Phone (____)______

Emergency Contact Information and Pick Up Information (other than parent/guardian)______

Name ______Relationship to student ______

Home Phone (____)______Work Phone (____)______Cell Phone (____)______Name ______Relationship to student ______

Home Phone (____)______Work Phone (____)______Cell Phone (____)______Name ______Relationship to student ______

Home Phone (____)______Work Phone (____)______Cell Phone (____)______

Student Previous School Information______

Last School Attended______City, State, Zip ______

Grade ______School Year ______

Is your child presently under an expulsion order from any other school district? Y N

Is your child presently under consideration for expulsion? Y N

Is your child presently involved in the Juvenile Justice system? Y N

English Language Learner Information (All new students should fill out a Home Language Questionnaire)

Does the student speak a language other than English? Y NWhat language? ______

Primary Language of Household: English SpanishOther ______

Special Services Information______

Is your child receiving special education services? Y N

Does your child have a current 504 plan? Y N Is it in: Academics Health

Was your child in any Gifted/Talented Programs? Y N Please list: ______

Is Mom or Dad military? Y N

Medical Information______

Is your child taking any medications regularly? Y N If yes, please list: ______

Student Medication Request Release Agreements are available at the school office. This form must be completed for any medication a student will need to take during school hours.

Known Medical Problems:______

Special Medical Instructions:______

If your child has a severe allergy that could result in anaphylactic shock, we must receive a physician statement stating so and a sufficient supply of their prescribed medication to be kept at the school for your child's use in the event of an emergency.

Physician name:______Address ______City ______State ______Zip ______Phone (____)______

Parent/Guardian Signature ______Date ______

(Do not sign this form if any of the statements are incorrect)