STUDENT REGISTRATION FORM

Date _______                                                                                                              Grade _______

Has child attended school in the

South Pike School District previously? _____

Student’s Legal Name _____________________________________________________________

^{Last                                           First                                         Middle}

Social Security Number ______________________________ Birth Date _____________________

Birth Place _________________________________________ B.C. # _______________________

^{City                                          County                     State}

Race (circle one) B-Black             H-Hispanic          I-American Indian                A-Asian          W-White

Gender (circle one)           Male    Female                                          Bus # ________________________

Last School Attended _________________________________ Withdrawal Date ______________

                    Address ______________________________ Has student ever been expelled/suspended from school? ____

                    Phone ________________________________Has student ever been in special education classes? ________

                                                                                                                                 Is student eligible for gifted program? ___________________

RESIDENCE INFORMATION

Physical 911 Address ______________________________________________________________

Mailing Address (if different) ________________________________________________________

Home Phone _____________________________________ Cell Phone _______________________

PARENT/LEGAL GUARDIAN DATA

Child lives with : (circle all that apply)     Father      Mother    Stepfather     Stepmother     Legal Guardian

1^st Parent/Guardian __________________________________________________________________

^{Last Name                                  First Name                                 Middle Name                Relationship}

Address ____________________________________________Occupation ______________________

     ^{Full Address if different from student}

Employer ___________________________________________ Work Phone ____________________

2^nd Parent/Guardian___________________________________________________________________

^{Last Name                                  First Name                                 Middle Name                     Relationship}

Address ____________________________________________Occupation ______________________

                      ^{Full Address if different from student}

Employer ___________________________________________ Work Phone ____________________

Emergency Contact/Check-Out Information

#1________________________________________________________________________________

                ^{Name                                                        Address                                                     Phone                                   Relationship}

#2________________________________________________________________________________

                ^{Name                                                        Address                                                     Phone                                    Relationship}

#3_________________________________________________________________________________

                ^{Name                                                        Address                                                     Phone                                    Relationship}

Current Medical Conditions _________ Current Medications ____________ Allergies _____________

I certify that the above information is true.

___________________________  __________________

^{Signature of parent/legal guardian                                            Date}