Form #201 Sec - Enrollment - Rogers Public Schools

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FOR OFFICE USE ONLY
Form #201 SEC (Rev. 3/11/10)
Locker # ____________________
ENROLLMENT - ROGERS PUBLIC SCHOOLS
Student ID#__________________
Student’s Full Legal Name_________________________________________________________________________________________Grade _______________
Last
First
Middle
Bus # ______
______
Car Rider
Walker
Student Vehicle Information (if applicable): __________________________________________________
am
pm
Make
Model
Color
License #
Enrollment Date __________________ Birthdate ______________ Age today ______ Race _______ C H B AI AO
Male
Female
Student’s Mailing Address ________________________________________________________ Zip _____________ Home Phone_________________________
Student’s 911 Address __________________________________________________________________Zip____________________________________________
Directions to Home __________________________________________________________________________ Distance From School ______________________
Father's Name _________________________________________________________ Place of Emp. _________________________________________________
First
Last
Telephone # ____________________________Cell___________________
E-mail Address ________________________________________________
Mother's Name ________________________________________________________ Place of Emp. _________________________________________________
First
Last
Telephone # ____________________________Cell___________________
E-mail Address ________________________________________________
Step-Mother _________________________________________________________ Place of Emp._________________________________________________
Father
First
Last
Telephone # ____________________________Cell___________________
E-mail Address ________________________________________________
Student is living with
Father and Mother
Mother and Step-father
Father and Step-Mother
Father Only
Mother Only
Other
__________________________________________________________________________
ALL Persons who may take child from School____________________________________________________________________________________________
Persons who may NOT take student from School: (If biological parent, please provide legal documentation.)______________________________________________
Emergency names & telephone # _______________________________________________________________________________________________________
School last attended: ___________________________________
City, State, Zip _______________________________________________________
List any other Rogers Schools including Garfield or Lowell this child has attended _________________________________________
STUDENT MEDICAL ALERT
List all persons living in household, including adults:
(list special problems)
Name
Relationship
Grade
_____________________________
_______________________________________________________________________
_____________________________
_______________________________________________________________________
_____________________________
_______________________________________________________________________
_____________________________
_______________________________________________________________________
_____________________________
_______________________________________________________________________
_____________________________
_______________________________________________________________________
_____________________________
_______________________________________________________________________
_____________________________
_____________________________
Doctor ______________________________ Dentist ____________________________
_____________________________
_____________________________
Extra classes: REACH (Gifted/Talented)
Speech
Resource
ESOL
Other (please specify) ____________________________________________________.
Is this student currently expelled from a previous school? Yes
No
Was this student being considered for expulsion or suspension from a previous school? Yes
No
Has a move been made in the last three (3) years for a parent to work in poultry processing, canning or other agriculture related industry? Yes
No
Have the students been in the Migrant Program? Yes
No
In case of an emergency, the school has my permission to seek medical treatment for my child.
Note: According to Arkansas statute, falsification of information may result in the student’s removal from school.
_________________________________________________ Date _______________
Parent/Guardian Signature

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