ONEIDASPECIALSCHOOL DISTRICT CONFIDENTIAL REGISTRATION INFORMATION
(Please PRINT all Information)
Enrollment Date______
Student Name______Grade______
Last NameFirst NameMiddle Name
Social Security or
StudentState ID Number:______Sex: Female Male
Date of Birth:______ Race: (Check ALL that Apply)
Birthplace/City:______American Indian
BirthCounty:______Asian
BirthState:______Black
Birth Country:______Hispanic
Citizenship:______Pacific Islander
Mother’s Maiden Name:______White
What is the first language this child learned to speak?______
What language does this child speak most often outside of school?______
What language do people usually speak in this child’s home?______
Alerts (non-medical special instructions)______
Parent Guardian Information:
If natural parents are divorced or separated a copy of the Court Order awarding custody of the child is REQUIRED. Is a copy of the Court Order and/or Guardianship Papers attached: ______Yes ____Does Not Apply
Primary Legal Guardian(s)#1: Name all legal guardians who live in the household with this child. (Mom & Dad or just Mom or just Dad or Foster Parents) DO NOT list Stepparents unless they are one of the Primary Legal Guardians
Main Contact:______Relationship______
Address______
*Primary Phone #______Emergency #______
Employer ______Work #______
Other #______Cell______
Primary E-mail 1______Alternate E-mail 2______
*This is the telephone number that receives automated telephone calls.
Secondary Legal Guardian(s)#2: Name the secondary guardian(s) who does NOT live in the household with this child (if any)
Contact______Relationship______
Address______
*Primary Phone #______Emergency #______
Employer ______Work #______
Other #______Cell______
Primary E-mail 1______Alternate E-mail 2______
Student Name______
Last NameFirst NameMiddle Name
Notes (Individuals other than parent guardian who may pick up the child)
Name______Phone Numbers______
Name______Phone Numbers______
Name______Phone Numbers______
Name______Phone Numbers______
School History
Pre-schools attended (if kindergarten student):______
LastSchool Attended:______
Address:______
Other Schools Attended:______
Is this student currently under suspension/expulsion from another school?_____Yes _____No
Has this student previously received Special Education Services?_____Yes _____No
Has this student previously received services under Section 504?_____Yes _____No
Is this student currently receiving Special Education Services?_____Yes _____No
Is this student currently receiving services under Section 504?_____Yes _____No
If YES, list program(s):______
______
Medical Contacts:Doctor’s Name:Phone Number:______
______
Dentist’s NamePhone Number:______
______
I, the undersigned, do hereby authorize officials of the OneidaSpecialSchool District to contact directly the persons named on this form and do authorize the named physician or dentist to render treatment as may be deemed necessary in an emergency, for the health of said child. In the event the parent/legal guardian/custodian, physician, dentist, or other person named on this form cannot be contacted, the school officials are hereby authorized to take whatever action is deemed necessary in their judgment for the health of the aforesaid child. I will not hold the OneidaSpecialSchool District responsible for emergency care and/or transportation for said child.
If any of the information I have provided in this form changes during the course of the school year, I will contact the child’s school in writing immediately to provide updated information. If I choose to withdraw my child from the OneidaSpecialSchool District for any reason, it is my responsibility to go to my child’s school and complete a formal withdraw prior to enrolling in another school system.
I certify that all of the information I have provided is true and correct and that deliberate misrepresentation of the information may subject me to prosecution under applicable State and Federal Laws. I certify that I am the legal parent/guardian/custodian of the child identified on this enrollment form.
Signature of Parent/Legal Guardian/Custoidan:______Date:______
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