Enrollment form tes.pdf - Junction City School District

Please Print Clearly
Territorial Elementary School
Student Enrollment Form
OFFICE USE ONLY
Student ID __________ SSID _________________
Bus # ______
Today’s Date __________________ New Re-enrolling Entering Grade __________
Legal Guardian:_____________________________________
Student Name: Legal Last Name Legal First Name Legal Middle Name Also known as:
Birthdate (Month/Day/Year) Gender Birthplace: City State
US Citizen
M F
Yes No
Are you Hispanic or Latino Yes, Hispanic/Latino No Primary Language Spoken by Student
English Other ______________________________________
Race (Please fill out separate Race & Ethnicity
Primary Language Spoken by Parent/Guardian (other than English)
Information Form in your registration packet.
Please check all that apply.)
Mother: Father:
Primary Household Information
Primary Household Parent/Guardian #1
Last name
First Name
(Where student resides)
Primary Household Parent/Guardian #2 (Where student resides)
Last name
First Name
Student lives with
Mother Father Both Parents
Foster Guardian Joint Custody Mother & Stepfather
Father & Stepmother Aunt/Uncle Grandparent
Other ________________
Resident
Address
Street Apt # City State Zip
Mailing Address
(if different from above)
Primary Household Parent/Guardian #1 Phones
Please check primary phone; include area code
Street Apt # PO Box City State Zip
Primary Household Parent/Guardian #2 Phones
Please check primary phone; include area code
Home phone:
________________________________________________________
Work Phone ______________________ Employer__________________________
Cell phone
__________________________________________________________
Email Address: _________________________________________________________
Home phone: ________________________________________________________________
Work Phone ______________________ Employer__________________________________
Cell phone ___________________________________________________________________
Email Address: __________________________________________________________________
Is this a temporary living situation? Yes No If yes, please indicate where the student is living: ___ in a shelter ____ in a car ____ in a motel/hotel ___ with more than one family
____ in a house or apartment ___ with friends or a relative ___ Other (please specify): _________________________________________________________________________________
Does the living situation checked above result from a loss of housing or from economic hardship? Yes No Not sure
Secondary Household Information
Receive Report Cards/Mailings?
Yes No
Secondary Household Parent/Guardian #1 Secondary Household Parent/Guardian #2
Last name First Name Last name First Name
Secondary
Address
Mailing
Address
(if different
from above)
Secondary Household Parent/Guardian #1 Phones
Please check primary phone; include area code
Home phone: _________________________________________________________
Work Phone ______________________Employer____________________________
Cell phone ___________________________________________________________
Street Apt # City State Zip
Street Apt # PO Box City State Zip
Secondary Household Parent/Guardian #2 Phones
Please check primary phone; include area code
Home phone: ________________________________________________________________
Work Phone ____________________Employer____________________________________
Cell phone _________________________________________________________________
Email Address:
Email Address:
Is there a joint custody or parenting plan in effect? Yes No (If Yes, plan must be on file with the school for enforcement)
Is there a restraining order in effect? Yes No (If Yes, legal papers must be on file with the school for enforcement)
Restraining order is against: Mother Father Other _______________________________________________________________
Student Cell Number and Email Address:

Previous Schools Attended
Has your child ever attended a Junction City School?
Yes No Has your child been retained? Yes No. If yes, what grade? _____
All previous schools attended (list most recent first):
School Name Address City State From To Grade Levels Public Private
Special Services
Has your child ever qualified for or been enrolled in a Special Ed Program? Yes No
Has your child ever qualified for or had a 504 Plan? Yes No
Has your child ever participated in: Title I/LAP IEP Gifted OT/PT Speech Therapy Other _____________________
Has your child ever been enrolled in an English as a Second Language Program?
Yes
No
Siblings
Last Name First Name School Grade
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Contacts (fill in information for at least two contacts) NOT PARENT OR GUARDIANS
Primary Contact (other than parent/guardian)
Last name
First Name
Relationship to child Phone #1 (include area code) Phone #2 (include area code)
Second Contact
(other than parent/guardian)
Last name
First Name
Third Contact
(other than parent/guardian)
Last name
First Name
Student Release Authorization
In the event that the school is unable to contact the parent/guardian, I authorize that my child may be released to the person(s) listed above.
Legal Parent/Guardian Signature ____________________________________________________________________________ Date ______________________________________
NOTICE: Only students who physically reside within the boundaries of the Junction City School District and nonresident students who have obtained a
release from their resident districts and have been officially accepted by the Junction City School District may legally attend school within the Junction City
School District. Recognizing this legal requirement, I hereby verify that the student named above physically resides within the Junction City School District
boundaries or has obtained a release from his/her resident district and has been officially accepted by the Junction City School District.
I certify the foregoing information to be true and recognize that falsification or omission of information could result in modification of the school or program
placement for this student, including sending the student to his/her resident district.
Legal Parent/Guardian Signature________________________________________________________________________ Date______________________________
Fax to First Student ___________ __________ Enter Pentamation _________ Program Tracking ________
8-10-2010AH