Enrollment Information

DALE PUBLIC SCHOOLS-STUDENT INFORMATION/ENROLLMENT FORM

Today’s Date_______________________________           Soc. Sec. No. _______  ________  _________

First Name_____________________Middle Name________________Last Name___________________

Race___Gender____ Date of Birth___________Grade (for upcoming school year 2014-2015)_________

Birth Place (city & state)___________________________________ Previous School_________________

Are you a resident________transfer_______ Bus Rider under 1.5 miles_______over 1.5 miles_________

PARENT CONTACT #1-Name____________________________________relationship________________

Address_________________________________City__________________State_________Zip_________

Primary Phone________________Work Place____________________Work Phone__________________

Check all that apply:__parent/guardian__has custody__access to records__pick-up rights

__emergency contact__lives with       Email address___________________________________________

PARENT CONTACT #2-Name____________________________________relationship________________

Address__________________________________City_________________State__________Zip________

Primary Phone _________________Work Place____________________Work Phone________________

Check all that apply:__parent/guardian__has custody__access to records__pick-up rights

__emergency contact__lives with         Email address______________________________________

OTHER THAN THE ABOVE LISTED-WHO CAN WE CONTACT IN CASE OF EMERGENCY IF PARENTS ARE UNREACHABLE-

Emergency Contact Name_________________________relationship______________Phone__________

Emergency Contact Name_________________________relationship______________Phone__________

Course Requests:          (to be filled out by counselor)                   Electives:    (list in order of importance)

English______________Course Number________               _______________Course Number________

Math_______________ Course Number________               _______________Course Number________

Science______________Course Number________              _______________Course Number________

History______________Course Number_________             _______________Course Number________

 

DO YOU LIVE OR WORK ON FEDERAL PROPERTY?____YES___NO    

 IF YES, PLEASE LIST WORKPLACE___________­­­­­­­­­­­­­­­­­­­­­­­________________________________

MEDICAL INFORMATION:  Does your child take medication on a daily basis?______Yes ______No

If yes, what medication? ________________________for what medical condition?_____________

Does your child have any of the following health concerns?

______Asthma________ADD/ADHD__________Diabetes (type 1 or type 2)______Hearing Impairment

______Seizure Activity/Epilepsy______Vision Impairment_______Allergies_______Heart Condition

Other (explain)____________________________________

In case of accident or serious illness, I request the school to contact me.  If the school is unable to reach me, I hereby authorize the school to call the doctor indicated below and follow his/her instructions.  If it is impossible to contact the physician, the school may make whatever arrangements are necessary. 

Parent’s Signature__________________________Family Doctor_______________Phone____________

ALERT NOW (this is a recording sent to parent/guardian in case of emergency or when school is out due to bad weather).  This will need to be numbers you can receive calls on during the day AND/OR  in the evenings. 

Phone #1_______________________________________Phone #2_______________________________

Permission to use Internet at school__Yes__No/Publish picture (yearbook, newspaper, etc.)__Yes __No 

Does your child receive any special services?__________IEP             If yes, for what?________________

Is English the primary language spoken in the home?_________Yes___________No

Are there any further medical/legal/or custody concerns that the school should know?  Please provide documentation:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

Parent’s Signature- the above information is correct and class schedule is approved:

____________________________________________________________      Date_________________