Sis-10w - Student Enrollment Form Page 4
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1
2
3
4NOT LIVING WITH STUDENT
(
LEGAL PARENT/GUARDIAN
cont.)
Is this parent/guardian a member of the Armed Services, National Guard or Reserves?
Yes
No
Military Status (check one):
Traditional Reservist / M-Day
Active Duty (Title 10)
Federal Technician (Title 32)
G
Deployed?
Yes
No
U
A
Branch of Service (check one):
R
D
Army
Marine
Air National Guard
Navy Reserves
I
Air Force
Coast Guard
Army Reserves
Marine Reserves
A
N
Navy
Army National Guard
Air Force Reserves
Coast Guard Reserves
Does this person work for the Federal Government or work on Federal Property?
Yes
No
EMERGENCY CONTACT INFORMATION
(Person To Notify In Case Of Emergency Other than First or Second Parent/Guardian Contact)
F
Check one:
Mr.
Mrs.
Ms.
Other (specify): ______________________
Relation: ___________________________
I
R
______________________________________
______________________________________
____________________________________
S
Last Name
First Name
Email Address
T
__________________________
__________________________
__________________________
__________________________
Home Phone #
Cellular Phone #
Pager #
Work Phone # (include ext.)
EMERGENCY CONTACT:
(circle one)
Call Sequence 1
2
3
4
5
(Person To Notify In Case Of Emergency Other than First or Second Parent/Guardian Contact)
Check one:
Mr.
Mrs.
Ms.
Other (specify): ______________________
Relation: ___________________________
S
E
______________________________________
______________________________________
____________________________________
C
Last Name
First Name
Email Address
O
N
__________________________
__________________________
__________________________
__________________________
D
Home Phone #
Cellular Phone #
Pager #
Work Phone # (include ext.)
EMERGENCY CONTACT:
(circle one)
Call Sequence 1
2
3
4
5
SCHOOL SUPPLEMENTARY INFORMATION
Legal First, Middle Initial & Last Name HIDOE School Attending
DOB
Grade
Relationship
Other
1.
Children
In
2.
HIDOE
Schools:
3.
4.
Parent/Legal Guardian Signature:
Date:
FOR SCHOOL USE:
Page 4/4, SIS-10W Rev 12/16 SPAB
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