Student Registration Form - Jefferson Parish Public School System Page 2

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FATHER’S INFORMATION
Student resides with:
Yes
No
Last Name:
First Name:
Middle:
Address (if different from student):
City:
Zip Code:
Home:
Work:
Cell:
Email:
Date of Birth:
Deny access to Student Progress Center:
Yes
No
Is this parent affiliated with the military (active, reserve, retired)?
Yes
No If so, which branch?
__________________________
Student resides with:
Yes
No
MOTHER’S INFORMATION
Last Name:
First Name:
Middle:
Address (if different from student):
City:
Zip Code:
Home:
Work:
Cell:
Email:
Date of Birth:
Deny access to Student Progress Center:
Yes
No
Is this parent affiliated with the military (active, reserve, retired)?
Yes
No If so, which branch?
__________________________
GUARDIAN’S INFORMATION
(Complete only if the student resides with someone other than a birth parent)
Step Parent
Grandparent
Foster Parent
Other (specify) _____________________________________
Grandparent
Foster Parent
Last Name:
First Name:
Middle:
Address (if different from student):
City:
Zip Code:
Home:
Work:
Cell:
Email:
Is this guardian affiliated with the military (active, reserve, retired)?
Yes
No If so, which branch? _________________________
EMERGENCY CONTACTS
#1 Last Name:
First Name:
Relationship:
Address:
City:
Zip Code:
Has permission to check out my child:
Yes
No
Home:
Work:
Cell:
#2 Last Name:
First Name:
Relationship:
Address:
City:
Zip Code:
Has permission to check out my child:
Yes
No
Home:
Work:
Cell:
#3 Last Name:
First Name:
Relationship:
Address:
City:
Zip Code:
Has permission to check out my child:
Yes
No
Home:
Work:
Cell:
MIGRANT EDUCATION SURVEY
Yes
No
In the past three years, has anyone in the household done any agricultural or fishing work?

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