Office Use Only School Year: _____ _____ _____ ____ ____ ____
CANAL CONGIN SACCARAPPA PRE K WMS WHS
2015-2016
WESTBROOK SCHOOL DEPARTMENT Student Information Form
Last Name: ___________________ First Name: ______________ Middle Name: ___________ Enrolling as:
K
Gender:
Male
Female
Birthdate: ___________________________
Birth City & State ______________________
Current Age: ________ ________ Year
Ethnic Group: Is the individual Hispanic/Latino? Yes (Check all that apply) American Indian or Alaska Native Native Hawaiian or other Pacific Islander Primary Language: ___________________________ Refugee
Immigrant
Month
No Asian White
Black or African American
Secondary Language: _____________________________
U.S. Arrival Date: _______________________
Parent/Guardian Information Father
OK to Pick Up
(First Name, Last Name)
Y
Legal/Shared Custody
N
Y
Lives With
N
Y
N
Receives Mailings Y
N
Mailing Address (if different from Physical Address) Physical Address: _____________________________________________________________ Street Apt. _____________________________________________________________ City State Zip
Home Phone:
Work Phone:
Cell Phone:
Email Address:
Ext:
Mother
Employer:
OK to Pick Up
(First Name, Last Name)
Y
Legal/Shared Custody
N
Y
Lives With
N
Y
N
Receives Mailings Y
N
Mailing Address (if different from Physical Address) Physical Address: _____________________________________________________________ (If different Street Apt. than above) _____________________________________________________________ City State Zip
Home Phone:
Work Phone:
Cell Phone:
Email Address:
Ext:
Employer:
If student resides with a stepparent or another guardian, please complete the following:
Adult Name
Relationship
(First Name, last Name
(Step, Foster, etc.)
OK to Pick Up Y
N
Legal Custody Y
N
Lives With Y
N
Receives Mailings Y
N
Mailing Address (if different from Physical Address) Physical Address: ________________________________________________________ Street Apt. ________________________________________________________ City State Zip
Home Phone:
Work Phone:
Cell Phone:
Email Address:
Ext:
Employer:
EMERGENCY SCHOOL CLOSINGS In the event that school is dismissed early due to weather or other evacuation reasons, please check the appropriate alternative that you would like us to implement for your child: Send home on regular bus
Call me @ ____________________________
EMERGENCY CONTACTS In the event of illness or emergency, and parent/guardian cannot be reached, the following list of people are authorized to release my child from school. Please limit to 3 emergency contacts. Adult Name (First Name, Last Name)
Relationship to student
OK to Pick Up
Home Phone
Cell
1.
Y
N
2.
Y
N
3.
Y
N
Please list any siblings who attend Westbrook Schools: Name _____________________________________ Name _____________________________________ Name _____________________________________
School _______________________________ School _______________________________ School _______________________________
Special Services Information: Does this child receive any special education, 504 or ESL services?
Yes
Work
No
If yes, please specify the program(s): _________________________________________________ Services received outside of the classroom: ___Reading
___Math
___Occupational Therapy
___Speech
___Gifted/Talented
___ Behavior Concerns
Previous School
___Physical Therapy
___Emotional Concerns
___Nurse/Medication
___Social Work/Social Skills
City, State
Classroom Teacher
Grade
HEALTH INFORMATION Doctor’s Name (First Name, Last Name)
Hospital Preference ____Maine Medical Center
Office Phone
____Mercy Hospital
Medical Alert / Health Issues (Such as asthma, diabetes, allergies, chronic problems-be specific) Medications currently taken by student Name of med. _________________________________ Time taken: _____________ Name of med. _________________________________ Time taken: _____________ Name of med. _________________________________ Time taken: _____________
I give my child permission to take the following medications during the school year ___ Tylenol (regular)
___ Tylenol (Extra-Strength)
___ Advil
___ Tums
___ Cough Drops
Required Signature: By signing below, I approve the medications checked above, affirm that I reside in Westbrook and will provide proof of residency upon request, and that all information given is accurate. (Please notify the school of any changes during the year). Thank you.
Page 1 of 2. School Year: 2015-2016. WESTBROOK SCHOOL DEPARTMENT. Student Information Form. Last Name: First Name: Middle Name: ______. Enrolling as: K Gender: Male Female Birth City & State. Birthdate: Current Age: ______ ______. Year Month. Ethnic Group: Is the individual Hispanic/Latino? Yes No.
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