Fillable Daviess County Public Schools Enrollment Form (Page 2 of 3) in pdf

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Legal Name of Student:

(Last)___________________________________________ (First)________________________________ (Middle)______________________________

How does student get to school daily? Please circle one.

NT – Not transported by school bus

T1 – Ride bus over one mile twice daily

T2 – Ride bus under one mile twice daily

T3 – Ride bus over one mile once daily

T4 – Ride bus under one mile once daily

T5 – Special Services bus

If child is to ride bus to/from address different than home, please list:

Name of person receiving child from school bus _________________________________________________________________

Address student is picked up from or delivered to ___________________________________________________ Telephone #_________________________

In case of early school dismissal, I want my child to ride regular bus: ___________

My child will be picked up: __________

My child will ride bus to an alternative destination: ________________________________________________________________

In case of accident or serious illness, the school will attempt to contact me. If the school is unable to contact me, the school will seek

appropriate medical treatment.

Family Physician________________________________________________________________________ Telephone #____________________

Dentist________________________________________________________________________________ Telephone #____________________

List and identify problems and/or medical conditions (such as asthma, allergies, diabetes, seizures, etc.) that should be known to school

personnel_______________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

Emergency Medication(s) ______________________ Regular Medication(s)_____________________ Dosage____________________________

Notify School Nurse at Initial Entry.

(An Authorization to Give Medication Form must be on file for any medication to be given to a student during the school day

Emergency Information:

In case of an accident or emergency of any kind, when parent/guardian cannot be contacted, please call and/or release my child to one of the

following:

Only the persons listed below will be allowed to pick up your child. No one other than the parent or legal guardian may check a

student out of school until this form is on file in the office.

Any person entering the building must sign in at the school office and provide photo ID. If they are picking up a student, they must sign the checkout

sheet in the office. No student is ever dismissed from the classroom unless the teacher is notified by the office. The student will not be allowed to

leave with anyone not listed on this form, or if the legal guardian cannot be contacted by phone to give the school permission to release their child.

Name___________________________________________________ Relationship______________________ Telephone #__________________

My child DOES NOT HAVE PERMISSION to leave with the following: Please note that if this is a parent of the child, the school MUST

HAVE LEGAL DOCUMENTATION to keep a parent from checking out his/her child.

Name___________________________________________________ Relationship______________________ Telephone #__________________

KRS 158.155 requires that a parent or guardian of a child who has been adjudicated guilty or previously expelled for homicide, assault, or violation of

state law or school regulations relating to weapons, alcohol or drugs must notify a new school of that fact by a sworn statement given to the school at

the time of registration.

_____ Yes, my child has been convicted of one or more of the above violations.

_____ No, my child has never been convicted of any of the above violations.

I will: 1) Read the discipline code handbook on line.

I will read the Student Agenda Handbook on line.

( )

2) Request a printed copy of discipline code.

Request a printed copy of Student Agenda Handbook.

My child has permission to be in videos produced for DCPS Cable 74, DCPS Web TV, and videos used for school use only. My child’s photograph

may be used in the newspaper, on bulletin boards, in displays, on the DCPS website, school yearbook, student directory, or in other types of

educational publications.  YES

 NO