*Use student’s name as it appears on the birth certificate *Must be completed by the child’s parent/legal guardian
School ____________________
New Student
Grade _________ Teacher ___________________
Returning Student
Student’s Last Name __________________________________First Name _______________________________Middle _______________________ Male or Female Date of Birth _____/____/________ Place of Birth _________________________ Soc. Sec. # _______-_____- ________ (circle one) (City/State) Address ___________________________________________________________________________________________________________________ (Number) (Street) (City) (State) (Zip Code) Main Phone (
) _______-_________
U.S. Citizen ___
Exchange Student ___
Non U.S. Citizen___
WE WANT TO KEEP YOU INFORMED Cell Phone # for Text Alert ( ) _______-_________ Email Address for Email Alert __________________________ 1) Is the student Hispanic/Latino? (Cuban, Mexican, South or Central American, Puerto Rican or other Spanish culture) 2) What is the student’s race? (List all that apply) ___ White ___ Black or African American
___ Asian
Alert Now Calls in Spanish? Yes ____ No ____ Yes ____ No ____
___ American Indian or Alaskan Native
___ Native Hawaiian or Other Pacific Islander
**Has this child ever had or currently does have any of the following: IEP Yes ____ No ____ Section 504 Yes ____ No ____ Intervention Plan (Special Education Services)
Yes ____ No ____
What school did this child attend previously? __________________________________________________________________________ (Name) (School District) (City/State) Has this child ever attended a Canton City School before? Yes ____ No ____ If yes, name of school____________________________ Has this child ever attended a Pre-school? Yes ____ No ____ Where? ______________________________ How many years? ______ CHILD’S PARENTS ARE:
Married
Separated
Divorced
Widowed
Never Married
Single
Remarried
*Any person listed on this form will be contacted in the event of an emergency. If no contact is allowed—do not give address/phone info
Address if different from child’s ___________________________________________________________________________ Employer _________________________________________________________ FATHER: ______________________________________________________
Work Phone ________________________ Phone _____________________________
Address if different from child’s ___________________________________________________________________________ Employer _________________________________________________________
Work Phone ________________________
*STEP PARENT: *(only if married to parent) ______________________________________________Phone________________________ Address if different from child’s ___________________________________________________________________________ Employer _________________________________________________________
Work Phone ________________________
LEGAL GUARDIAN: __________________________________________________________________ Phone _______________________ Relationship to student _________________________________ Address if different from child’s ___________________________________________________________________________ Employer _________________________________________________________
Work Phone _____________________
OTHER THAN THE ABOVE PARENTS/GUARDIANS, LIST TWO ADDITIONAL CONTACTS WHO CAN PICK UP YOUR CHILD IN THE CASE OF AN EMERGENCY AND WE ARE NOT ABLE TO REACH YOU: Name __________________________________Relationship____________________ Address ___________________________________ Phone _____________________ Name __________________________________Relationship____________________ Address ___________________________________ Phone _____________________
(COMPLETE EMERGENCY MEDICAL FORM ON REVERSE SIDE)
FOR OFFICE USE ONLY POR ____ Birth Cert ____ Imm/Health ____ Legal Doc ____ Internet ____ Records ____ Lunch Status ____ Dir ____ OE TE SA GW TW SC SF14____
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Try one of the apps below to open or edit this item. Registration Form revised 1_21_09_Spanish.pdf. Registration Form revised 1_21_09_Spanish.pdf. Open.
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Registration Form â International Conference - Adwitya 2016. 1. ... If more than one person from an organisation or institution wishes to register, ... Family Name.
Applications of Microwave Antennae 2016â. Savitribai Phule Pune University,. IEEE ComSoc Pune Chapter & IETE Pune Centre Technically Sponsored st th.
Cell Phone (_____)_____-______ ... information and may disclose such information to the above-named Insurance Company(ies) and ... consent will end when my current treatment plan is completed or one year from the date signed below.
(Name of State/Country). MATC appreciates your cooperation in completing the following information, which is needed to meet State and Federal reporting.
Registration Form â International Conference - Adwitya 2016. 1. Registration Details. Please note: If more than one person from an organisation or institution ...
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Date. Time Slot. Available (Y / N). A. Saturday June 23rd. 8:00A to 12 N. B. Saturday June 23rd. 12 N to 4 PM. C. Saturday June 23rd. 4 PM to 8 PM. D. Saturday ...
NOTE : ALL INFORMATION SHOULD BE FILL IN ENGLISH CAPITAL LETTERS ONLY. 1 NAME OF SECRETARIAT. : 2 NAME OF DEPARTMENT. : 3 NAME OF INSTITUTE / OFFICE. : 4 OFFICE ADDRESS. : PHONE NUMBER. 5 NAME AND DESIGNATION OF HEAD OF. INSTITUTE/OFFICE. CONTACT NUM
born in any State (any of the 50 states, the Commonwealth of Puerto Rico, the district of Columbia, Guam, American Samoa, the. Virgin Islands, the Northern ...
