Early Education Application For Enrollment printable pdf download

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Early Education Application for Enrollment: Ferguson-Florissant School

Day □

Evening/Saturday □

Attendance Area __________

Child’s Legal Name

Sex

(Last)

(First)

(Middle)

Nickname

Address

Home Phone

(Street)

(City)

(Zip Code)

Date of Birth

Birth Weight

Social Security Number ___________________________

Race:  Asian  Black  Hispanic  American Indian  White  Hawaiian/Pacific Islander  Multi-Race (non-Hispanic)

Language usually spoken in the home:

Allergies or significant medical condition now or at birth:

Father (or Guardian)

Mother (or Guardian)

Name ________________________________________________

Address ______________________________________________

Home Phone __________________________________________

Daytime/Cell Phone ______________________________

_____

Daytime/Cell Phone _____________________________

______

E-mail address ________________________________________

Birthdate _____________________________________________

Employer _____________________________________________

Address _________________________ Phone _____________

Address ________________________ Phone _____________

Hours of Employment: From _____ To_____ # of Days______

Last Grade Completed in School ________________________

If parents are divorced or are not together, court order with custody agreement and parenting plan is provided.

Yes No

Other Children in the Home

Name _________________________________________________________ Birth Date _____________________________________

Was family enrolled in Parents as Teachers?

 Yes

 No Where? ______________________________________________

Student may be released to mother, father, and:

Student may not be released to:

Emergency phone contacts of 3-4 persons authorized to pick up child if parent(s) cannot be reached

Name

Address

Phone

Relationship

Emergency Authorization: In an emergency, I hereby authorize the school to make such arrangements as necessary. I also

authorize the hospital/physician/dentist to perform necessary procedures. I prefer my child be taken to

or a close-by hospital, if necessary. I understand that the cost of medical attention and ambulance are the responsibility of the

parent. My child’s doctor is____________________________________ and can be reached at ______________________________ .

(Phone)

Signature of Parent (legal guardian if child is in custody of anyone other than parent)

Today’s Date

Ferguson-Florissant School District, 1005 Waterford Drive, Florissant, MO 63033

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Early Education Application For Enrollment

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