Elementary Registration Form PreK EC K EC
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M or F Male (Please circle gender)
(Please circle grade)
_______________
___________________
(Enrollment Date)
(For office use only)
STUDENT INFORMATION Student’s Last Name:
_______________________________ First (Legal) Name: _________________________
Middle (Legal) Name: _______________________________ Preferred Name: Student’s Address:
_______________________________ ___________________________ ______________ (Street)
Date of Birth:
_________________________
(City)
(Zip Code)
__________________ Place of Birth: ___________________________ ______________ (City)
Home Phone:
(____)_____________
(State)
Race: ___________________________ Black or African American (White, Black, Hispanic, American Indian, Other)
FAMILY INFORMATION Name of person(s) student lives with: ______________________________________________________________
Foster Parent Relationship to Student: (Circle) Both Parents
Mother
Father
Grandparent(s)
Foster Parent
Stepparent(s)
Other
Mother’s Name: _______________________ Employer: _________________ Work Phone: (___)____________ Father’s Name:
_______________________ Employer: _________________ Work Phone: (___)____________
Mother’s Cell:
________________________________
Father’s Cell:
_________________________________
Parent’s Email Address: ___________________________________________________________________________ Names of siblings who attend Hoopeston Area Schools: Name: _________________________
Grade: ____
Name: _________________________
Grade: ____
Name: _________________________
Grade: ____
Name: _________________________
Grade: ____
Is any immediate family an active member of the U.S. Military? No YES or NO
Who? _____________________
EMERGENCY INFORMATION In case of an emergency, whom should we call? Parents – Please list yourself if you’re to be called first. 1st Contact: _____________________ Phone (___)____________ Relationship (to student): __________________ 2nd Contact: _____________________ Phone (___)____________ Relationship (to student): __________________ 3rd Contact: _____________________ Phone (___)____________ Relationship (to student): __________________
TRANSPORTATION INFORMATION Will your student walk home from school?
No YES
or
NO
Will your student be picked up at school?
YES No
or
NO
Will your student ride a bus after school?
YES No
or
NO
/
Most regularly by whom? ___________________
Which bus will your student ride AFTER school? Please do not check the school your student attends. _____ Early Childhood
_____ Maple
_____ Honeywell
_____ John Greer
_____ H.S./Country
Health Information Form In an effort to keep school staff informed so they can best meet your child’s needs, Please check any health issues that your child has. ____ ADD/ADHD
____ Allergies (seasonal or otherwise)
____ Anxiety
____ Asthma
____ Bipolar Disorder
____ Bleeding problems
____ Bone/Joint problems
____ Bowel/bladder problems
____ Cardiac/Heart problems
____ Diabetes
____ Frequent colds/respiratory infections
____ Frequent headaches /migraine headaches
____ Frequent stomachaches
____ Hearing problems
____ Seizures
____ Sleeping problems
____ Speech problems
____ Vision problems
____Other: ________________________________________________________________________________________________ Please list any specific allergies: ____________________________________________________________________________ ___________________________________________________________________________________________________________ Please list any medications your child will need to take at school: ____________________________________________ ___________________________________________________________________________________________________________ Please list any medications your child routinely takes outside of school: _______________________________________ ___________________________________________________________________________________________________________
If your child has any serious medical conditions, please speak directly with the building principal and/or your child’s teacher regarding your concerns. -------------------------------------------SPANISH VERSION------------------------------------------En un esfuerzo por mantener al personal escolar informado por lo que mejor puede satisfacer las necesidades de su hijo, por favor marque cualquier problema de salud que tiene su hijo. ____ ADD/ADHD
____ Alergias estacionales (o no)
____ Ansiedad
____ Asma
____ Trastorno bipolar
____ Problemas de hemorragia
____ Problemas de huesos/ coyonturas
____ Problemas con la vejiga Y intestino
____ Problemas cardiacos
____ Diabetes
____ Frequentes infecciones respiratorias
____ Frecuentes dolores de Cabeza/migrañas
____ Frequentes dolores de
____ Problemas de audición
____ Ataques estómago
____ Problemas de sueno
____ Problemas de habla
____ Proglemas de la visión
____ Otro: _______________________________________________________________________________________________ Por favor anote cualquier alergia especifica: _______________________________________________________________ Por favor, indique todos los medicamentos que su hijo tendrá que tomar en la escuela: ______________________ ___________________________________________________________________________________________________________ Por favor, indique todos los medicamentos que su hijo toma habitualmente fuera de la escuela: _____________ ___________________________________________________________________________________________________________
Si su hijo tiene alguna condición medica seria, hable directamente con el director de la escuela y/o el maestro de su hijo acerca de sus preocupaciones.