Student Enrollment Form
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1Ring Lardner Middle School
Grade______
Student Enrollment Form
Name: _________________________________________________________________________ Male: ______ Female: _________
Last
First
Middle
Birth Date: __________________________ Age: _________________ Place of Birth:_____________________________________
City
State
Ethnicity (check one) White ______ Black______ Hispanic______ Native American ______Asian_______Other
__________________
If more than one checked please circle your ethnic priority
Home Address:_______________________________________Phone:____________E-mail:________________________________
Street
Previous School:__________________________________________________________ Grade: ___________________________
Name
Address
Father’s Name:_____________________________________________Birth Place:________________________Education:_______
Last
First
Middle
highest grade
Place of Employment:__________________________________________________Work Phone:_____________________________
Step Parent Name: ____________________________________________________ Work Phone: ____________________________
Mother’s Name
Birth Place:_________________________Education:_______
:_______________________________________________________
Last
First
Middle
highest grade
Place of Employment:__________________________________________________Work Phone:_____________________________
Step Parent Name: ____________________________________________________ Work Phone:_____________________________
Student Lives With:
Both Parents
Mother Only
Father Only
Mom/Step Dad
Dad/Step Mom
Grandparents
Guardian:_____________________________________
Foster Parents:_____________________________________________
name
name
Emergency Contact:________________________Relationship:_________________Phone:_____________
use back for additional space
Language other than English spoken in home:______________________________ Does your child have asthma?
no
yes
Was the student receiving Special Education services at their last school?
no
yes (please ask for temporary placement form)
Was the student receiving services through a Section 504 Plan at their last school?
no
yes
Are there any special academic, behavioral, medical, or legal matters we need to know about?
no
yes (explain)
use back for additional space
Is there any person who does not have permission to contact your child at school?
no
yes (give name and explain)
use back for additional space
Names of other minor children living at home:
Name
Birth Date
Name
Birth Date
I authorize Niles Community Schools to consent to medical treatment for my child in my absence. I also accept
_______________________________________
responsibility for payment of medical services rendered.
signature
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