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Enrollment

Please complete the form below. Required fields marked with an asterisk *

STUDENT INFORMATION

Gender:*
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Student Lives With:*
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Ethnic Code
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Primary Language Spoken at Home:
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Primary Guardian Contact Information

Secondary Guardian Contact Information

Resident Address:

State*
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Mailing Address(If different from Resident Address):

State
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Is there a Joint-Custody or Parenting Plan in effect? If Yes, the plan must be on file with the school for enforcement.*
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Is there a Restraining Order in effect? If Yes, legal papers must be on file with the school for enforcement.
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Restraining Order is against:
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CHILD CARE

Does the Student attend Child Care?
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Child Care Contact Information

Support Services:

Has your child ever qualified for or been enrolled in a Special Ed program?*
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Has your child ever qualified for or had a 504 plan?*
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Has your child ever participated in:
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Has your child ever had Speech Services?*
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Did your child attend Pre-School?
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Has our child ever been retained?*
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When injury, illness, or other non-emergency situations occur involving your child, we want to be able to quickly reach families or other responsible adults.  In the event we cannot reach a parent/guardian, please list persons in the local area you trust to provide care for your child.

Primary Contact Information

Primary Contact Address

State*
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Secondary Contact Information

Secondary Contact Address

State
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STUDENT HEALTH

Does the student have a Life-Threatening Health Condition? If yes, please complete the following.*
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ASTHMA

Will the student have an inhaler at school?
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Doctor's Contact Information

ANAPHYLAXIS

Does the student have an EPI pen?
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Doctor's Contact Information

SEIZURES

Will the student have any medications at school?
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Doctor's Contact Information

OTHER SPECIAL CARE NEEDS(Including Diabetes, Heart, or Neurological conditions)

Will the student have medications at school?
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Doctor's Contact Information

OTHER HEALTH CONDITIONS

Does the student have any medical conditions not referenced above?*
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Will the student take any medications at school?
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Does the student have any food allergies?
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Does the student need a milk substitute?
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If Yes, please select from the following:
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Please read and check the following statements below:*
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Confirmation Email