LivingstonCounty Board Of Education

Student Registration Form

School Name: ______Today’s Date______

Office Use Only

Entry Date/Code / Bus # / TCode / Parking #

Student Name______Nickname______

(Last) (First) (Middle)

Social Security # ______- ______-______Birthday_____-______- ______

Mother’s Maiden Name______

Ethnic Category: (Please circle all that applies)

American Indian/Alaska Native Asia Black or African American

Hispanic or Latino Native Hawaiian or OtherPacific Islander White

Enrollment History

Has your child ever attended school in the Livingston County School District? Yes or No

If yes: School attended ______Year(s) Attended______

Has your child ever attended school in Kentucky? Yes or No

School last attended

Name______

Address______Phone (____)______Fax (___)______

Special Programs

Has your child ever been enrolled in a special program?

(GT. Speech, Special Ed etc) Yes or No

Transportation to/from school (Please check one)

___NT (Not transported by bus) ___ T1 (Transported by bus twice daily more then 1 mile)

___T2 (Transported by bus twice daily less than 1 mile) ___ T3 (Transported by bus once daily more than 1 mile)

___T4 (Transported by bus once daily lessthan 1 mile) ___T5 (Special Transport – Handicapped bus)

Please list all other children less than 18 years of age living in the PRIMARY HOUSEHOLD

Name______DOB______Relation to student______

School Attending______Grade____

Name______DOB______Relation to student______

School Attending______Grade____

Name______DOB______Relation to student______

School Attending______Grade____

Name______DOB______Relation to student______

School Attending______Grade____

Student Name______Grade_____ Homeroom______

Social Security #____-____-______Birthday___/__/____ Male _____ Female______

Parent/Guardians Living in Same Household

Please list below only the person or persons with whom the student lives.

Home Address: Street Number______Street Name______

City______State______Zip Code______County Of Residency______

PO Box______City______State______Zip Code______

Home Phone ______Student’s Cell Number______

Check only if applicable: ___ Shelter ____Motel

_____ Family lives in house or apartment shared with friends or other family members

_____ Student lives in Friends/Family member’s home other thanwith parent/guardian

Student lives with: Relation to student: ______

1.(Last Name)______(First Name)______(Middle Name)______

Cell Phone (___) ______Employer: ______Work Phone (___) ______

E-mail______

Student lives with: Relation to student: ______

2. (Last Name)______(First Name) ______(Middle Name)______

Cell Phone (___) ______Employer: ______Work Phone (___) ______

E-mail______

______

___Please note:Check if you are NOT the natural parent and have legal documents for the school stating guardianship.

The school must have a copy for the student records.

___Please note: Check if you have any legal restrictions for student. The school must have it on file. ______

Parent/Guardians Living at an Address Different From Student

Please list name of parent/legal guardian,who may have rights to this student’s academic record, pick-up rights, etc.

Home Address: Street Number______Street Name ______

City______State______Zip Code______Home Phone______

PO Box______City______State______Zip Code______

Relation to student______

  1. (Last Name)______(First Name)______(Middle Name)______

Cell phone (___) ______E-mail______Employer:______Work Phone (___)______

Relation to student______

  1. (Last Name)______(First Name)______(Middle Name)______

Cell phone#______E-mail______Employer: ______Work Phone ______

Residency Verification: The residency information provided on thisform is true and accurate as of this date.

Signature of Parent/Guardian______Date______