Enrollment Form 2016-17 Page 2
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2SECONDARY HEAD(S) OF HOUSEHOLD
Does the child have a second parent/second residence? Yes No If yes, with whom?
Mother Only
Stepmother/Father
Other:______________________
Father Only
Stepfather/Mother
Joint Custody? Yes
No
Current Physical Address: ________________________________________________________________________________
(STREET ADDRESS)
(CITY)
(STATE)
(ZIP)
(COUNTY)
Current Mailing Address: ________________________________________________________________________________
(if different)
(STREET ADDRESS)
(CITY)
(STATE)
(ZIP)
Should this household be included in all mailings? Yes No
Okay to release student to second household parent Yes No
If you answered “No” to either of these questions, please attach legal documentation; specific to this child
and legal documentation; specific to communication with the Secondary Household parent.
SECONDARY HOUSEHOLD DATA
SECONDARY RESIDENCE 1
SECONDARY RESIDENCE 2
Head of Household Name/Title (L,F,M)
Relationship Type
Occupation/Employer
Employer Phone
*Additional Notes for above Phone Number
Cell Phone / Pager
*Additional Notes for above Phone Number
Email Address
EMERGENCY CONTACT INFORMATION
Calling Order
Name
Relationship Type
Work Phone
Cell Phone
Home Phone
1)
2)
If a medical emergency exists, the school is
Doctor
Doctor
authorized to take appropriate action on behalf of
the child. The family will assume all medical costs.
Dentist
Dentist
Yes No Preferred Hospital ________________
OTHER SIBLINGS LIVING AT HOME
Name
Gender
Birthdate
School
Grade
M F
/
/
M F
/
/
M F
/
/
HEALTH INFORMATION
Medical information is confidential and will be shared with personnel on a need to know basis.
Special Health Conditions Diabetes Heart Asthma Seizures Other (Explain) ______________________________________________________
Allergies Insects/Beestings Medication Food Environmental (Explain all)___________________________________________________________
Is student currently taking any prescription medications? Please list:_______________________________________________________________________
SPECIAL NEEDS INFORMATION
Special Program Received at Prior School: Special Education Speech & Language 504 Plan Title 1 Services Other (Explain)________________
Please circle the information/activities you wish to exclude your student from:
MISCELLANEOUS INFORMATION
Student Directory
Armed Forces Recruited Access
School Travel
Photos from School Publications
I certify that all information is true and valid and that I am authorized to enroll this student:
SIGNATURE: _______________________________________ Date: ________________________
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