Student Enrollment Form (Elementary School Or Middle School) Page 3
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3SECTION IV: EMERGENCY CONTACTS
The following people have my permission to check out my child from school:
Contact #1 (Non‐parent/non‐legal guardian)
Contact #2 (Non‐parent/non‐legal guardian)
__________________________________
______________________________________
Name
Name
__________________________________
______________________________________
Address
Address
________________
_____ ________
________________
______
__________
City State Zip Code
City State Zip Code
__________________________________
______________________________________
Telephone Number(s)
Telephone Number(s)
__________________________________
______________________________________
Relationship to Student
Relationship to Student
Contact #3 (Non‐parent/non‐legal guardian)
Contact #4 (Non‐parent/non‐legal guardian)
__________________________________
_______________________________________
Name
Name
__________________________________
_______________________________________
Address
Address
________________
_____ ________
________________
______
__________
City State Zip Code
City State Zip Code
__________________________________
_______________________________________
Telephone Number(s)
Telephone Number(s)
__________________________________
_______________________________________
Relationship to Student
Relationship to Student
____________________________________________________________________________________________
SECTION V: PHYSICIAN / MEDICAL INFORMATION
_______________________________________
_____________________________________
Physician
Telephone
List any medical conditions to which the school needs to be alerted:
_______________________________________
_____________________________________
Medical Alert 1
Medical Alert 2
SECTION VI: MISCELLANEOUS INFORMATION
1. Has student been enrolled in any special programs?
_____ Yes
_____ No
If Yes, name of Program ______________________________________________________________
(For example: Special Education/IEP, ESOL, EIP, Special Needs Preschool, Tutoring, Gifted/AIM)
2. Is this student currently serving a suspension or expulsion from another school district? ____Yes
____No
3. Name and address of school previously attended ________________________________________________
_________________________________________________________________________________________
4. List Cherokee County Schools attended _______________________________________________________
5. Directions from school to home _____________________________________________________________
(Note: For items 6, 7 and 8, please see school staff member).
6. What bus (or buses) do you ride?
Morning Bus Number
st
Load
_____ 2
nd
Load
___________
_____1
Afternoon Bus Number ___________
st
Load
_____ 2
nd
Load
_____1
7. If you transfer to a second bus:
Morning Bus Number
st
Load
_____ 2
nd
Load
___________
_____1
Afternoon Bus Number ___________
st
Load
_____ 2
nd
Load
_____1
8. Are you a car rider? ___Yes ___ No If your car ride was not available, what bus would you ride? ______
Declarations:
I understand that all the facts contained on this Enrollment Form are true and correct, and, if found to be false or
erroneous, will lead to the immediate removal of my child from this school.
I understand that I must report any change of residence to this school, regardless if that change in residence is outside
of this school’s attendance zone.
_________________________________________
_____________________
________________
e
Signature of Parent/Legal Guardian
Relationship
Dat
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