Fillable Daviess County Public Schools Enrollment Form printable pdf download

DAVIESS COUNTY PUBLIC SCHOOLS

IF THERE IS A CHANGE DURING THE YEAR IN ANY

DO NOT WRITE IN THIS SPACE (For School Use)

Grade/Home Room ______

Social Security Card ____

INFORMATION ON THIS FORM (ADDRESS, PHONE, HEALTH,

AM Bus _____ PM Bus _____

OCCUPATION, ETC.), THE SCHOOL MUST BE NOTIFIED

Proof of Residence _______

IMMEDIATELY. FALSIFICATION OF ENROLLMENT

Records ______

Birth Certificate ______

INFORMATION MAKES THIS APPLICATION NULL AND

Immunization _____

Physical Exam ______

Vision Exam _____

Dental Screening _____

VOID.

Enrollment Information (Please print and complete front and back of form.)

Legal Name of Student:

(Last)_______________________________________ (Jr,III, etc)______ (First)_______________________ (Middle) ______________________

Male _____ Female _____ Grade ______ Nickname ___________________________ Home Language _______________________________

Date of Birth (Month)_________ (Day)_________ (Year)_________

Race/Ethnicity: ___White ___Hispanic/Latino ___Black/African American ___Asian ___American Indian/Alaska Native ___Native Hawaiian/Pacific

Islander;

Country of Birth _______________________

Do you rent/own home ___Rent ___Own

Student’s Address: (Street)________________________________________________ (City)_________________ (State)_______ (Zip)_______

Student’s Mailing Address (if different): (Street)_________________________________ (City)_________________ (State)_______ (Zip)_______

Please check any of the following services that apply to your student:

____Individual Education Plan (IEP)

____504 Plan

____EL

____ Gifted

Last School Attended: __________________________________________________________________________________________________

Parents/Guardians Living Within Household With Student

Last Name___________________________________ Suffix_______

First Name____________________________________ MI________

First Name___________________________________ MI_________

Gender_____ Relationship to Student____________________________

Phone #______________________ Work #____________________

Cell Phone #_____________________________________________

Place of Employment______________________________________

E-mail Address___________________________________________

Siblings Living Within Household

Last Name___________________________________ Suffix_______

First Name___________________________________ MI_________

Birth date_______ / _______ / _______ Gender______

Birth date_______ / _______ / _______ Gender______ Grade________

Grade________

Relationship to Student_____________________________________

Currently attending a Daviess County School? _____Yes _____No

Name of School___________________________________________

Last Name___________________________________ Suffix_______

First Name___________________________________ MI_________

Birth date_______ / _______ / _______ Gender______ Grade________

Birth date______ / _______ / _______ Gender______ Grade_________

Relationship to Student_____________________________________

Currently attending a Daviess County School? _____Yes _____No

Name of School___________________________________________

Parents/Guardians Living at Another Address (If Applicable)

Does this parent/guardian have joint custody?

_____Yes ____No

Does this parent/guardian have joint custody?

_____Yes _____No

Last Name___________________________________ Suffix_______

First Name___________________________________ MI_________

Gender_____ Relationship to Student____________________________

Address_________________________________________________

City____________________________________________________

Phone #_______________________ Work #___________________

Cell Phone #_____________ Place of Employment______________

Cell Phone #____________ Place of Employment_______________

E-mail Address___________________________________________

Is there a court order restricting this parent/guardian’s access to this

Is there a court order restricting this parent/guardian’s access to this student?

student? ____Yes ____No

____Yes ____No

(If yes, a copy of the court order MUST be provided.)

IMPORTANT: Please provide ONE PHONE NUMBER for contact via the OneCall Now automated telephone messaging service. This number will receive emergency and/or

information messages from the district and school. Your OneCall Now phone number is: _____________________________________

Parents/guardians can add other numbers by going to and selecting “Parents,” then click on “Communications,” then the OneCall Now link. If you do not have

internet access, contact your school for help.

Daviess County Public Schools Enrollment Form

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