DALE JUNIOR HIGH/HIGH SCHOOL-
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 )__________________
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__________
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________
***College-Bound/Work-Ready Curriculum requires either 2 computer or 2 foreign language classes. Core Curriculum DOES NOT, but parents must notify the school in writing that they agree to Core Curriculum. Sometimes, vo-tech or other elective activities make it difficult to fit in 2 foreign language classe.
******CONTINUE ON BACK*******
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?_____________
Permission to use Internet at school__Yes__No/Publish picture (yearbook, newspaper, etc.)__Yes __No
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)____________________________________
Does you child receive special services?______Yes _______IEP ________504________Title 1_________N/A
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.
_______________________________________________________Doctor’s Name_____________________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_______________________________
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:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
***OHLAP-Oklahoma’s Promise-It is the responsibility of the parent and/or student to check updates and curriculum requirements for this program. Is your child on Oklahoma’s Promise? _____Yes _____No (for more info-go to www.oklahoma’spromise.com
***NCAA Clearinghouse (for college athletes) is the responsibility of the student to enroll and meet the requirements set forth by the organization.
Parent’s Signature- the above information is correct and class schedule is approved:
____________________________________________________________ Date_________________