LACROSSE SCHOOL DISTRICT

STUDENT REGISTRATION/EMERGENCY INFORMATION FORM 2016-2017

Grade Level:______

Student Information:

Legal Last Name:______First ______Middle______Nickname:______

Physical Street Address:______City______Zip______

Mailing Address, if different:______City______Zip______

Gender: £ Male £ Female Birthdate:______

Birth City:______Birth State:______Birth Country:______Birth County:______

Primary Language Spoken at Home: ______Student’s E-Mail:______

Primary Home Phone Number:______Student’s Cell Phone Number:______

Life Threatening Condition:

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Does your child have a life threatening condition (i.e. diabetes, heart condition, asthma, allergic reaction that results in anaphylactic shock)? £ Yes £ No

Special Services Information:

Is your student currently on an IEP?
£ Yes £ No / Is your student currently on a 504 Plan? £ Yes £ No / Is there a perceived handicap? £ Yes £ No

Primary Household Information (Where the student resides the majority of the time):

Student Lives With: (Circle) Both Parents Mother Only Father Only

Mom/Stepdad Dad/Stepmom Grandparents Other: ______

Parent/Guardian 1 of Primary Household

Name:______Address:______

Home Phone:______Cell Phone:______

Employer:______Work Phone:______

E-Mail Address:______

Parent/Guardian 2 of Primary Household

Name:______Address:______

Home Phone:______Cell Phone:______

Employer:______Work Phone:______

E-Mail Address:______

Emergency Contact Information (other than parent):

Emergency Contact #1

Name:______Address:______

Home Phone______Cell Phone:______Relationship to student______

Employer:______Work Phone______

Emergency Contact #2

Name:______Address:______

Home Phone______Cell Phone:______Relationship to student______

Employer:______Work Phone______

Emergency Contact #3

Name:______Address:______

Home Phone______Cell Phone:______Relationship to student______

Employer:______Work Phone______

Medical Information:

Physician:______Office Phone:______

Dentist:______Office Phone:______

Hospital:______Phone#______

School Age Siblings: Please list all other children from your household who attend school:

Name: ______Grade______Date Of Birth______

Name:______Grade______Date Of Birth______

Name:______Grade______Date Of Birth______

Secondary Household Information:

Is there a second household to send information to: £ Yes £ No

Name______Relationship To Student______

Mailing Address______

Home Phone #______Work Phone #______

Custody:

Is there a joint-custody or parenting plan in effect? £Yes £ No (If yes, plan must be on file with the school.)

Is there a restraining order in effect? £Yes £ No (If yes, legal papers must be on file with the school.)

Restraining order is against: Mother _____ Father______Other: ______


LaCrosse School District

Ethnicity and Race Data Collection Form 2016-2017

Student Name:______Date of Birth:______Grade:______

QUESTION 1. Is your child of Hispanic or Latino origin? (Check all that apply.)
NOT HISPANIC/LATINO / MEXICAN/ MEXICAN AMERICAN/ CHICANO
CUBAN / CENTRAL AMERICAN
DOMINICAN / SOUTH AMERICAN
SPANIARD / LATIN AMERICAN
PUERTO RICAN / OTHER HISPANIC/LATINO
QUESTION 2. What race(s) do you consider your child? (Check all that apply.)
AFRICAN AMERICAN/ BLACK / ALASKA NATIVE
CHEHALIS
WHITE / COLVILLE
COWLITZ
ASIAN INDIAN / HOH
CAMBODIAN / JAMESTOWN
CHINESE / KALISPEL
FILIPINO / LOWER ELWHA
HMONG / LUMMI
INDONESIAN / MAKAH
JAPANESE / MUCKLESHOOT
KOREAN / NISQUALLY
LAOTIAN / NOOKSACK
MALAYSIAN / PORT GAMBLE KLALLAM
PAKISTANI / PUYALLUP
SINGAPOREAN / QUILEUTE
TAIWANESE / QUINAULT
THAI / SAMISH
VIETNAMESE / SAUK-SUIATTLE
OTHER ASIAN / SHOALWATER
SKOKOMISH
NATIVE HAWAIIAN / SNOQUALMIE
FIJIAN / SPOKANE
GUAMANIAN or CHAMORRO / SQUAXIN ISLAND
MARIANA ISLANDER / STILLAGUAMISH
MELANESIAN / SUQUAMISH
MICRONESIAN / SWINOMISH
SAMOAN / TULALIP
TONGAN / YAKAMA
OTHER PACIFIC ISLANDER / OTHER WASHINGTON INDIAN
OTHER AMERICAN INDIAN

Parent/Guardian Signature:______Date:______

(Please double check that you answered both Question 1 and 2 on this page.)

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