SMITH COUNTY SCHOOLS

Student Enrollment Form

IS YOUR CHILD CURRENTLY SUSPENDED OR EXPELLED FROM YOUR PREVIOUS SCHOOL SYSTEM? _________ NO ____________ YES

IS YOUR CHILD CURRENTLY PLACED IN AN ALTERNATIVE SCHOOL OR ANY OTHER TYPE OF SPECIAL PLACEMENT? ______ NO ________ YES

Where choices are given, circle one.

LEGAL NAME _________________________________ SEX: M F GRADE_______

Last First Midde

DATE ENTERED ______________ RACE: Asian Black Hispanic White

BIRTHDATE ________________ SOCIAL SECURITY # ________________________

MORNING BUS # _______AFTERNOON BUS # _______ MILES RIDDEN ON BUS _________

CUSTODY: Both Mother Father Other_________________ HOMEROOM TEACHER ________________

PARENT OR GUARDIAN’S NAME __________________________________________

911 HOME ADDRESS __________________________________________

CITY ___________________________, STATE ____________ ZIP CODE _____________

TELEPHONE # ______________________ BIRTH CERTIFICATE # _______________________

MOTHER’S EMPLOYER ______________________________________PHONE _____________

FATHER’S EMPLOYERS ______________________________________PHONE _____________

SCHOOL LAST ATTENDED _________________________________

ADDRESS: __________________________________________________________________

IS YOUR CHILD IN: Title 1 (Remedial Reading) YES NO

Special Education (Resource) YES NO

DO YOU OR YOUR SPOUSE WORK ON FEDERALLY OWNED PROPERTY? YES NO

DOES YOUR CHILD TAKE ANY MEDICATION ON A REGULAR BASIS? YES NO

IF YES, PLEASE EXPLAIN AND GIVE ANY SPECIAL INSTRUCTIONS:

__________________________________________________________________________________

PERSON TO CALL WHEN PARENTS CANNOT BE REACHED. LIST SOMEONE WITH A PHONE:

NAME______________________________PHONE________________RELATION____________

NAME______________________________PHONE________________RELATION____________

IF YOU CANNOT BE REACHED AND YOUR CHILD SHOULD NEED EMERGENCY TREATMENT BY A PHYSICIAN OR HOSPITAL ATTENDANT, DO YOU GIVE YOUR PERMISSION FOR HIM/HER TO RECEIVED MEDICAL ATTENTION? YES NO

CHILD’S PHYSICIAN _________________________________PHONE_______________

LIST ANY PERSON(S) NOT ALLOWED TO SEE YOUR CHILD: _______________________

LIST ANY PERSON(S) NOT ALLOWED TO CHECK YOUR CHILD OUT OF SCHOOL:

IF AN UNAUTHORIZED PERSON COMES TO PICK UP YOUR CHILD, YOU WILL BE CONTACTED FOR VERIFICATION. IF WE ARE UNABLE TO CONTACT YOU, YOUR CHILD WILL NOT BE ALLOWED TO LEAVE SCHOOL. UNLESS A NOTE OR PHONE CALL IS PROVIDED BY YOU.

LIST PERSON(S) WHO MAY SIGN YOUR CHILD OUT OF SCHOOL:

LIST ANY INFORMATION WE NEED TO KNOW ABOUT YOUR CHILD (PHYSICAL/MEDICAL PROBLEMS, SUSPENSIONS, PROBATION, CUSTODY PROBLEMS, ETC.) ____________________________________________________

WHAT IS THE FIRST LANGUAGE YOUR CHILD LEARNED TO SPEAK?

_______ENGLISH OTHER _____________

WHAT LANGUAGE DOES YOUR CHILD SPEAK MOST OFTEN OUTSIDE OF SCHOOL?

_______ENGLISH OTHER______________

WHAT LANGUAGE DO PEOPLE USUALLY SPEAK IN YOUR CHLD’S HOME?

_______ENGLISH OTHER_______________

Parent Signature ________________________________________ Date ______________________