Student Registration And Directory Release Form

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Student   R egistration   a nd   D irectory   R elease   F orm  
 
School   O ffice   U se   O nly
Student   I D   N umber_________________         G rade________               E ntry   D ate____/_____/_____           B us   N umber   _ ________  
Parents/Guardians:   P lease   f ill   o ut   b oth   s ides   o f   t his   r egistration   f orm   f or   y our   s tudent.     P lease   p rint   n eatly.  
STUDENT   I NFORMATION  
Student’s   L egal   N ame:  
Last     _ ____________________________         F irst   _ ____________________________   M iddle________________________  
Date   o f   b irth     _ ____/______/______               S ex     _ _______   ( M   o r   F )             S ocial   S ecurity   N umber   _ ______-­‐_______-­‐_________  
Student’s   A ddress   _ _____________________________________________     A pt.   _ _______   _     Z ip   C ode   _ _____________  
Ethnicity:  
____   A m.   I nd./Alaskan   N ative  
History:  
Has   t he   s tudent   e ver   a ttended   s chool   i n   L ouisiana?   _ ____     ( Y/N)  
Has   t he   s tudent   e ver   a ttended   a n   [ district]   s chool?     _ ____     ( Y/N)  
____   A sian/Pacific   I slander  
Last   s chool   a ttended:  
____   B lack   ( not   H ispanic)  
School   N ame:_______________________   D istrict:   _ ____________  
____   H ispanic  
City:   _ ___________________     S tate:   _ ______     Z ip:   _ ____________  
____   W hite   ( not   H ispanic)  
Is   t his   s tudent   t he   s ubject   o f   a   c ourt   o r   c ustody   o rder?   _ ____   ( Y/N)  
____   O ther  
If   y es,   p lease   p rovide   a   c opy   o f   t he   o rder   t o   t he   s chool.  
Language:  
Exceptional   S tudent   S ervices:  
-­‐Spoken   a t   h ome:                             _ ___________________  
Has   t his   s tudent   e ver   r eceived   s ervices   a s   a n   E xceptional   S tudent?   _ ____   ( Y/N)  
-­‐First   s poken   b y   s tudent:     _ ___________________  
If   y es,   p lease   i ndicate   t he   s tudent’s   e xceptionality:   _ ___   G ifted     _ ___   T alented    
-­‐Most   o ften   s poken   b y   s tudent:   _ ______________  
Other:   _ ________________________________________________________  
PARENT/GUARDIAN   I NFORMATION  
Last   N ame   _ __________________________   F irst   N ame   _ _____________________________   R elation   _ ______________  
Address   _ __________________________   A pt.   _ _______   Z ip   C ode   _ ______      
D oes   t he   s tudent   r eside   a t   t his   a ddress?     _ ____   ( Y/N)  
Phone   N umbers:  
Home   _ ___________________________     C ell____________________________   W ork   _ __________________________  
Last   N ame   _ __________________________   F irst   N ame   _ _____________________________   R elation   _ ______________  
Address   _ __________________________   A pt.   _ _______   Z ip   C ode   _ ______      
D oes   t he   s tudent   r eside   a t   t his   a ddress?     _ ____   ( Y/N)  
Phone   N umbers:  
Home   _ ___________________________     C ell____________________________   W ork   _ __________________________  
Person   w ith   w hom   t he   s tudent   l ives   i f   n ot   t he   p arent/guardian:  
Last   N ame   _ __________________________   F irst   N ame   _ _____________________________   R elation   _ ______________  
Address   _ __________________________   A pt.   _ _______   Z ip   C ode   _ ______      
D oes   t he   s tudent   r eside   a t   t his   a ddress?     _ ____   ( Y/N)  
Phone   N umbers:  
Home   _ ___________________________     C ell____________________________   W ork   _ __________________________  
TRANSPORTATION  
Does   y our   c hild   n eed   a   b us   s top?     _ ____   ( Y/N)  
I f   y es,   y ou   m ust   f ill   o ut   a   b us   s top   r equest   f orm.
 
   
People   a uthorized   t o   p ick   u p   s tudent:  
Name________________________________   H ome   P hone   _ __________________     W ork   P hone   _ __________________  
Name________________________________   H ome   P hone   _ __________________     W ork   P hone   _ __________________  
Name________________________________   H ome   P hone   _ __________________     W ork   P hone   _ __________________  
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