Fillable Printable New Student Registration Form - Jersey Shore Area School District
Fillable Printable New Student Registration Form - Jersey Shore Area School District
New Student Registration Form - Jersey Shore Area School District
New Student Registration Form
Rev 11/13
_____ Student eligible for transportation
Jersey Shore Area School District
175 A&P Drive, Jersey Shore, PA 17740
Form
1
Office Use Only:
_____Immunization (on file)
_____Birth Certificate (on file)
_____Soc. Sec Card (optional)
_____Proof of Residency (on file)
Student # ___________________
Registration Date ______________________________ Grade _________ SH MS JS Elem Avis Elem Sall Elem
Student Name _________________________________ ___________________________ _____________________ SS# _______-_____-_______
Last Name First Name Middle Name Optional
Sex: M F Date of Birth ______/______/______ Birthplace ____________________________________ Home Phone# ( )
Month Date Year City State Unlisted? Y N
Did the child ever attend school in this district? Y N
Which School? _________________________ Grades? __________
Who has legal custody of student?
__________________
Adults who reside with child at above address:
Mother/Father Mother Mother/Stepfather Father Father/Stepmother Other __________________________
Father
Name__________________________________
Address _______________________________
______________________________________
Place of Employment ____________________
Primary Phone ( )
Secondary Phone ( )
Work Phone ( ) Ext _______
Email ________________________________
Mother
Name__________________________________
Address _______________________________
______________________________________
Place of Employment ____________________
Primary Phone ( )
Secondary Phone ( )
Work Phone ( ) Ext _______
Email _________________________________
Step Parent/Guardian
Name_________________________________
Address _______________________________
______________________________________
Place of Employment ____________________
Primary Phone ( )
Secondary Phone ( )
Work Phone ( ) Ext _______
Email ________________________________
NAME OF ALL CHILDREN AT CHILD’S ADDRESS
RELATIONSHIP TO CHILD
AGE
SCHOOL
GRADE
Parent Signature _________________________________________________________________________ Date __________________________
Home Address
House Number __________________Apartment Number ________________________________
Street Name ____________________________________________________________________
PO Box _______________________Borough/Township _________________________________
City ____________________________________________________ Zip Code ______________
Ethnicity – Please check:
Was the child in any of the following programs at his/her previous school?
If yes, please check all that apply:
