Submit to
[email protected]
Northwood Public School 2016 - 2017 Enrollment Information TODAY’S DATE ______________
GRADE _______
POWER SCHOOL # __________ (FILLED IN BY SCHOOL)
*This information is used many times throughout the school year, please remember to notify the school if ANY of this information changes* Phone # 2 _____________________ TEXT ALERT NUMBER Phone # 1 _____________________ (The first number listed will be the phone number that goes on the list for teachers. ) STUDENT NAME (LAST, FIRST , MIDDLE ) __________________________________________________________________ STUDENT PHYSICAL ADDRESS __________________________________________ CITY_________________ ZIP________ STUDENT MAILING ADDRESS _________________________________________ AGE
____
DATE OF BIRTH
____ / ____ / ______
CITY_________________ ZIP _______
SEX ____
ETHNICITY: WHITE ___ AMERICAN INDIAN OR ALASKA NATIVE ___ BLACK OR AFRICAN AMERICAN ____ HISPANIC OR LATINO ______ ASIAN _____ NATIVE HAWAIIAN/PACIFIC ISLANDER _____ FATHER (LAST, FIRST) _____________________________________________________ PHONE _______________________ EMPLOYER ________________________________________________________________ PHONE _______________________ MOTHER (LAST, FIRST) ___________________________________________________ PHONE _______________________ EMPLOYER _______________________________________________________________ PHONE _______________________ EMAIL ADRESS ____________________________________________________________________________________________ In the event of an EMERGENCY and the school is unable to reach you, please provide the information below. NAME
__________________________________ RELATIONSHIP_______________ PHONE ________________________
MEDICAL INFORMATION: ALLERGIES: NO____ YES____ NAME OF ALLERGY ______________________________ OTHER MEDICAL CONDITIONS _____________________ MEDICATIONS TAKEN REGULARLY __________________ Please list siblings under school age in your household for our census, thank you NAME ____________________ LAST NAME ____________________ LAST
________________________ FIRST ________________________ FIRST
_______________
____
____________
SEX
DATE OF BIRTH
_______________
____
____________
MIDDLE
SEX
DATE OF BIRTH
MIDDLE
* If you work at the Grand Forks Air Base are you considered Civilian ___ or Military___. Please fill out back page also.
Disclaimer: This questionnaire is intended to address the McKinney-Vento Act. Your child may be eligible for additional educational services through Title I Part A, Title I Part C-Migrant, Individuals with Disabilities Education Act (IDEA) and/or Title X, Part C, Federal McKinney-Vento Assistance Act, 42 U.S.C.11435. Eligibility can be determined by completing this questionnaire. It is illegal to knowingly make false statements on this form. If eligible, students are to be immediately enrolled in accordance with Bulletin 741, section 341. 1.
Is the student’s address a temporary living arrangement? ____ Yes ______ No (Note: If this is a permanent living arrangement or the family owns or rents their home, sign under item 6 and submit form to school personnel, thank you)
2.
Is the temporary living arrangement due to loss of housing or economic hardship? ___ Yes ___ No
3.
Where is the student currently living? (Check all that apply) ___
Temporarily with another family.
___
With an adult that is not a parent or legal guardian, or alone without an adult.
___ ___
In a hotel/motel. In a vehicle of any kind, trailer park or campground without running water/ electricity, abandoned or substandard housing.
___
Emergency Housing (i.e. FEMA Trailer or Rental Assistance)
___
In an emergency/transitional shelter.
___
Other (Must provide specific information)
4. Does your child have a disability or receive any special education services? (Check One) _____ Yes ____ No 5. Does your child exhibit any behaviors that may interfere with his or her academic performance? ___Yes ____ No 6. Would you like assistance with ____ uniforms ____ student records _____ school supplies _____ transportation ____ other? Describe:
Signature for question # 1 ________________________________________________
Thank you for taking the time each year to fill out this form.
