Today’s Date: ______
STUDENT ENROLLMENT FORM
Ironwood Area Schools
650 E Ayer St
Ironwood, MI 49938
Phone: 906-932-0932 Fax: 906-932-3082
Student Information
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Student LEGAL Last Name First Name Middle Name Gender Entering Grade
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Street Address City/State Zip Code Home Phone Number
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Student’s Cell Phone Number Date of Birth Place of Birth
Is your child a US Citizen? ___Yes ___No
Ethnicity (BOTH PARTS A AND B MUST BE ANSWERED)
Part A: Is your child Hispanic or Latino (a person of Cuban, Mexican, Puerto Rican, South or Central America or other Spanish culture or origin,
regardless of race)? ___Yes ___No
Part B: Choose one or more (please number in order of dominant ethnicity)
_____American Indian or Alaskan Native _____Asian American _____ Black or African American
_____Hispanic or Latino _____Native Hawaiian or Other Pacific Islander _____White
We encourage you to select an answer. If you do not, the US Department of Education requires the school district to supply an answer on your behalf.
Home Language Survey
What language is spoken in your home? ______What is your child’s primary language?______
Parent/Guardian Information
1. ______Resides with Student ___Yes ___No
Name Home Phone Number Cell Phone Number Relationship to Student
______
Email Address Work Place Work Phone Number
2. ______Resides with Student ___Yes ___No
Name Home Phone Number Cell Phone Number Relationship to Student
______
Email Address Work Place Work Phone Number
3. ______Resides with Student ___Yes ___No
Name Home Phone Number Cell Phone Number Relationship to Student
______
Email Address Work Place Work Phone Number
4. ______Resides with Student ___Yes ___No
Name Home Phone Number Cell Phone Number Relationship to Student
______
Email Address Work Place Work Phone Number
Other Children Living at Home
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Name Date of Birth Name Date of Birth
______
Name Date of Birth Name Date of Birth
Previous School Information
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Name of Last School Attended Phone Number Fax Number
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Address City State Zip
Has your child ever been evaluated for or received SPECIAL EDUCATION PROGRAMS OR SERVICES? ____ Yes ____ No
Does your child have a current IEP? ____ Yes ____ No
Has your child ever been retained? ____Yes ____No If yes, at what grade level(s)? ______
Has your child ever qualified for or had a 504 plan? ____ Yes ____ No If yes, please explain. ______
______
Has your child ever received Title services? ____ Yes ____ No If yes, ____ Math ____ Reading
Services student received at previous school: (CHECK ALL THAT APPLY)
____Speech ____Social work ____OT/PT ____ESL(English Second Language)/ELL(English Language Learner)
____ Other/Please explain: ______
Has your child ever been under disciplinary action (suspension/expulsion/etc.)? ____ Yes ____ No If yes, when? ______
Reason:______
Does your child have a behavior plan? ____ Yes ____ No
Medical History
Does your child have any known allergies? ____ Yes ____ No If yes, what? ______
Is your child on any medication? ____ Yes ____ No If yes, what?______
Will your child need to receive medication during school? ____ Yes ____ No
If yes, a permission to medicate form is required before the school can distribute medication.
Does your child have any medical concerns the school should be aware of? ____ Yes ____ No
If yes, please explain: ______
______
______
Emergency Contacts
Please list additional people the school can contact if you cannot be reached or are unavailable to pick up your child for any reason.
______ ______
Name Phone Number Relation to Student
______ ______
Name Phone Number Relation to Student
______ ______
Name Phone Number Relation to Student
Is there ANY court order(s) currently in effect pertaining to your child? (i.e., custody/parenting plans, school attendance orders, restraining
orders, etc.) ____ Yes ____ No If yes, legal papers must be on file with the school for enforcement.
Please Explain: ______
Additional information you would like to share:______
______
______
I affirm that all information provided is true and accurate. I understand any false information provided by me may subject me to legal penalties for perjury. Further, I agree to notify the school immediately of any address change.
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Signature of Parent/Guardian/Student (if 18 or over) Date