5010-A Revised 12/13 ARMSTRONGSCHOOLDISTRICT
Registration Form
School Year 20____ - 20____
SCHOOL: ______GRADE:______
Entry Date into United States Schools: ______Number of Years in United States Schools:______
All Kindergarten students must be 5 and all First Grade students must be 6 on or before August 31.STUDENT'S LEGAL NAME (Last, First, Middle,Suffix): / SEX: Male Female
Ethnicity: 1. American Indian/ 2. Asian/ 3. Black 4. Hispanic 5. White Alaskan Native Pacific Islander (Not Hispanic) (any race) (Not Hispanic)
911 STREET ADDRESS:
______
______/ Birthdate:(Month/Day/Year)
Birthplace:(City, State, & Country)
TOWNSHIP/BOROUGH: / COUNTY:
MAILING ADDRESS (IF DIFFERENT FROM THE 911 ADDRESS):
______
______/ Home Phone/Cell Phone(U=Unlisted)
( ) ______
( ) ______
FEMALE GUARDIAN'S NAME(Last, First, Middle):
Mrs. Ms. Miss / Birthdate: / Relationship (i.e. Mother, Stepmother, etc.):
Occupation: / Employer: / Work Phone:
( )
MALE GUARDIAN'S NAME(Last, First, Middle): (Suffix)
Mr. / Birthdate: / Relationship (i.e., Father, Stepfather, etc.):
Occupation: / Employer: / Work Phone:
( )
STUDENT LIVES WITH: Both Parents Mother Father Legal Guardian Foster Parent Group Home___
WHO HAS LEGAL CUSTODY OF THE STUDENT?______If custody papersexist, please supply one copy. (name) (relationship)
If custodian is not parent, an Armstrong School District Resident and Right to Free School Privileges Affidavit must be submitted. If the student lives in a foster or group home, a verification letter from the placing agency or group home must be submitted.
BROTHERS(Legal Name & Birthdate):
1. ______
2. ______
3. ______/ SISTERS(Legal Name & Birthdate):
1. ______
2. ______
3. ______
DESCRIBE LOCATION OF HOME(Use landmarks, description of your home, etc. Attach a small map, if necessary.)
PLEASE COMPLETE BACK OF FORM
TO BE COMPLETED BY PARENT OR GUARDIAN
LAST SCHOOL, GRADE, AND DISTRICT ATTENDED:______
______
SCHOOL YEAR ENTERED 9TH GRADE______(SENIOR HIGH SCHOOL STUDENTS ONLY) / HAS THE STUDENT PREVIOUSLY ATTENDED THE ARMSTRONG SCHOOL DISTRICT?
YES NO
IF YES, WHEN: ______
BUILDING: ______
PERTINENT INFORMATION ABOUT THE STUDENT YOU FEEL THE TEACHER SHOULD KNOW: ______
______
______
Signature of Parent/Guardian: ______Date: ______
TO BE COMPLETED BY OFFICE PERSONNEL (ANSWER ALL QUESTIONS)
1. Is the student entering from an early intervention program? Yes No
2. Does the student have an Individualized Education Program plan and receive special education services? Yes No
Exceptionality Class assignment ______(ex: MR, LD, ED, NI, MG, SLI) (ex: LS, LSS, ES, GS, SLS)
3. Does the student require special transportation? Yes No
If yes, explain: ______
4. Is the student in Title I and/or Extended School Day program(s)? Yes No
5. Has the following documentation been supplied? ____ Proof of Immunizations Proof of Birth ____ Proof of Residency Custody Papers Resident and Right to Free School Privileges Affidavit
6. Is the student's home language English? Yes No If no, a Home Language Survey Form ASD 5011must be completed.
7. GENERAL COMMENTS: ______
______
REGISTRATION BY: REGISTRATION DATE: ______
BUILDING: GRADE: ENTRY DATE: ______
PICKUP BUS - Number: Time:______Stop Name: ______WALKER _____
DROPOFF BUS- Number: Time:______Stop Name: ______WALKER _____