ENROLLMENT/WITHDRAWAL FORM Office Use Only

Has your child attended GB Schools in the past?

Yes

No

School Code:

Student's Name (Last, First, Middle):

Grade Enrolling Into:

Perm ID: UIC#

Birthdate:

Building: Gender: (circle)

Kdg Waiver?

Child's Birth Place (County/State): Yes

Enter Date:

Male

No

Birth Country:

Female

Student's Native Language:

Primary Language Spoken at Home: Primary Phone: □ Home □ Work □ Cell Ethnicity: *Hispanic/Latino?

Leave Date: ESL Screening? Yes

Yes

No

No

*A person of Cuban, Mexican, Puerto Rican, South or Central America or other Spanish culture/origin, regardless of race.

Address: City:

Race: *Circle one or more-use 1 & 2 to rank primary & secondary group Amer Ind or Alaskan Asian African Amer/Black Native Hawaiian/Pacific Islander White

Zip:

With whom does child live? (circle) Foster Care

Other

Both Parents

Mother/Stepdad

If eligible, will you use school busing? From home to school? From day care to school?

Yes

Yes

No

Yes

Father Only

Mother Only

Father/Stepmom

Blended Family

Physical Custody

Living on Own

Joint Custody

Day Care Name/Address:

No From school to home?

No

Legal Guardian

Yes

No

From school to day care? Yes No

Previous school:

 if your child has received Special Education Services □ Currently □ Previously

City/State:

 if your child has received 504 services □ Currently □ Previously

School Moving to: City/State:

 if your child received Speech/Lang Therapy? □ Currently □ Previously

Has your child participated in other GB Programs? Yes No

□ Parents as Teachers □ Children's Garden □ GPGS

□ GSRP

Parent/Guardian Information Mother's Name:

Employer:

Address (if different than above) :

Internet at home?

Job Title: Yes

No

e-mail address: Mailings Allowed: □

Contact Allowed: □

Is Mom active in the Military? Level of Education Completed: Phone (first Contact ) : □ Home

Yes

Student Lives With Mom: □

Mom has custody: □

No

□ Work

Country of Birth: Date of Naturalization: □ Cell Phone (second contact ): □ Home □ Work

Father's Name:

Employer:

Address (if different than above) :

Internet at home?

□ Cell

Job Title: Yes

No

e-mail address: Mailings Allowed: □

Contact Allowed: □

Is Dad active in the Military? Yes No Level of Education Completed: Phone (first Contact ) : □ Home □ Work

Student Lives With Dad: □

Dad has custody: □

Country of Birth: Date of Naturalization: □ Cell Phone (second contact ): □ Home □ Work

□ Cell

Other Children in the Family Name

Birthdate

School

Grade

Boy

Girl

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Health Conditions/Allergies: Add Health Condition: Comment: Add Health Condition: Comment: Add Health Condition: Comment:

Start Date: Start Date: Start Date:

In Case of Emergency: Names of persons who can assume temporary responsibility Name:

Relationship:

Home Phone:

Work Phone:

Cell Phone:

Medical Information Physician:

Physician's Phone:

Hospital Choice:

Hospital Phone:

Health Insurance: ● Medication given at school must be taken to the office in its original container. Generally a one day dose is recommended except where the prescription is long term. A form, which is available in the school office must be completed by the physician and placed on file in the school office. Medication taken at school must follow the guidelines as stated in the Student Rights and Responsibilities Handbook. ● In case of accident or serious illness, if the school is unable to contact me, my spouse or designated legal guardian, I hereby authorize the school to take my child to the physician named on this document. If it is impossible to contact this physician, the school may take my child to the hospital named on this document. If the school administration determines it would be in the best interest of my child's health and welfare, my permission is hereby given to use an ambulance. I hereby agree to all expenses incurred in the emergency case. ● I have read the current version of the Student Rights & Responsibilities Handbook, located at http://grandblanc.schoolfusion.us/ and understand it.

REQUIRED Parent/Guardian Signature: ___________________________________________________ Date: ____________________

NOTE: If there are any changes to this document, please provide proper documentation to the school office.

For Office Use Only New Student _____ Name Change: ____

Updated/Revised Information _____ Address Change: ____

Birth Certificate Presented?

Yes

No

Birth Certificate #: __________________________

School Change: ____

Grade Change: ____

Phone Change: ____

Date Faxed to Transportation: __________________ Bus #: _____________________

Teacher: _________________________________________ Rm #: ____________ MCIR: ____________________

Revised 1/19/2016

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