FOR REGISTRAR USE ONLY

STUDENT REGISTRATION FORM

DATE OF ENROLLMENT:

STUDENT ID #:

START DATE:

SCHOOL ASSIGNMENT:

Has this student previously attended Minot Public Schools? Yes _____ No _____ ...if no, please indicate name of previous school, city, state and zip ______________________________________________________ Previous school City State Zip

Section 1: Student/Contact Information

PLEASE PRINT

Student’s Legal Name__________________________________________________________________________________________________ (Last)

(First)

(Middle) (Preferred)

Birthdate_______________ Grade_ ______ Gender: Male_____ Female _____ Home Phone #_ ____________________________ (Required Field)

Home Address_________________________________________________________________________________________________ Street Address (Do Not list PO Box as street address)

City State Zip

Mailing Address _______________________________________________________________________________________________ Street Address (Can list PO Box)

City State Zip

Ethnic Category: Is this child Hispanic/Latino? Yes _____ No _____. Please choose the child's race: _____

American Indian/Alaska Native

_____

White/Caucasian

_____

Black/African American

_____

Asian

_____

Native Hawaiian/PacificIslander

_____

Other ___________________________________

Has this student ever been suspended? Yes _____ No _____ . Expelled? Yes _____ No _____. Name of Parent/Guardian

Student Resides With (X)

Employer

Daytime Phone (Work)

Cell Phone

Mother:

Step Mother: Father: Step Father: Guardian: Spouse: Student Cell Phone:

Military: Yes _____ No _____ If yes, what branch? ______________________________________ Rank_____________________ Section 2: Special Programs Does this student have a current Individual Education Plan (IEP) through Special Education?

Yes _____ No _____

If yes, please indicate primary disability_ ___________________________________________________________________________________ Does this student have a 504 Accomodation Plan (for such things as diabetes management, etc.)

Yes _____ No _____

Did this student participate in the Gifted and Talented program at their last school?

Yes _____ No _____

(REV 09/12)

Section 3: Medical/Emergency Information In case of a medical emergency and I cannot be reached, I authorize my child's doctor or any attending physician to administer emergency medical treatment for the child listed on the reverse side. As parent or guardian, I agree to assume all cost of treatment. Yes ____ No ____ Physician's name_____________________________________________________________Phone ________________________ Health Information (Check all that apply):

(Circle Y/N))

_____ No Known Health Problems

_____ Ear Tubes

_____

Asthma - Inhaler Dependent - Yes/No

_____ Hearing Aids

_____ Wheelchair

_____

Diabetic - Insulin Dependent - Yes/No

_____ Frequent Ear Infections

_____ Contacts/Glasses

_____

Seizures/Epilepsy - Medication Required - Yes/No

Life Threatening Allergies: Yes _____ No _____ (Please list) _____________________________________________________ Allergies: Yes _____ No _____ (Please list) ___________________________________________________________________ Student Requires Epi-pen at school? Yes _____ No _____ Student requires rescue inhaler at school? Yes _____ No _____ Student needs to take medication at school? Yes _____ No _____ Student has a medical condition school should be aware of? Yes _____ No _____ (Please list) ___________________________ Section 4: Additional Emergency Contacts Contact (Last, First Name)

Relationship

School Hours Phone #

1.

( )

2.

( )

Home,work or cell?

Second Mailing (For Example: a non-custodial parent) Individual's Name (Last, First)_________________________________________________Relationship_________________________________ Mailing Address _______________________________________________________________________________________________________ City State Zip

Section 5: Parent/Guardian Signature My relationship to this student is: ____ Parent

____

Step Parent

____

____ Legal Guardian (Documentation needed)

Foster Parent ____ ____

Grandparent ____

Sibling

____

Group Home

Person having lawful Court Order (Order needed)

____ Other (please specify) __________________________________________________________________________________________________ I hereby certify that all the information contained in this form is true and accurate to the best of my knowledge. Printed Name:_______________________________________________________E-mail address ____________________________________________ Signature:____________________________________________________________________________________ Date __________________________

Items scanned and collected: _____ Photo ID (View) _____ Birth Certificate _____ Immunization Record _____ ELL/ESL Form _____ Custody/Divorce Docs School District: Minot MAFB

DBGR

For Office Use Only: _____ _____ _____ _____

Nedrose

F/R Lunch Form Proof of Residence (type provided) ______________________________________ Title VII Student Eligibility Form for Native Americans Completed Records Requested (Date Requested ____________________)

Enrollment Process

South Prairie

Glenburn (Military)

Other _________________________