Fillable Printable Student Registration Form - Alexandria City Public Schools

Student Registration Form - Alexandria City Public Schools

Revised 3/2015 Communicaons Oce dnb

STUDENT REGISTRATION FORM

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Alexandria City Public Schools

Student’s Last Name: First Name: Middle Name:

Student Address: Street Apt #

City State Zip

r Male r Female Date of Birth: Mo: Day: Year: Country of Birth: Grade:

*Is this student Hispanic or Lano? (choose only one)

*What is the student’s race? (choose one or more)

Last School Aended: r Public r Private

Address: City State Zip

If not an Alexandria City school, has student EVER aended Alexandria City Public Schools? r Yes r No

If Yes, please provide the following: School: Year: Grade:

If a language other than English is spoken in the student’s home, what is that language?

r No,notHispanicorLano r Yes,HispanicorLano(personofCuban,Mexican,PuertoRican,SouthAmerican,

CentralAmerican,orotherSpanishcultureororigin,regardlessofrace)

r AmericanIndian/Alaskan

r Asian

r Spanish rAmharic r Arabic rOther(pleasespecify)

r BlackorAfricanAmerican

r NaveHawaiianorOtherPacicIslander

r White(apersonhavingoriginsinanyoftheoriginal

peoplesofEurope,theMiddleEastorNorthAfrica)

Parent/Guardian:

Is the City of Alexandria your legal residence? r Yes r No

IfNo,hasanexcepontopolicybeenapproved? r Yes r No

Parent/Guardian #1:

HomePhone:( ) -  CellPhone:( ) -  EmailAddress:

r Father r Stepfather r Legal Guardian

r Mother rStepmother r Foster Parent

Other(pleaseindicaterelaonship):

Address: rAddressisthesameasstudent’saddressabove

Street Apt #

City State Zip

Parent/Guardian’s preferred language of communicaon?

r English r Spanish rAmharic r Arabic rOther(pleasespecify)

LastName: FirstName: r Male rFemale

Employer:

WorkAddress:

WorkPhone:( ) - Ext:

Parent/Guardian #2:

HomePhone:( ) -  CellPhone:( ) -  EmailAddress:

r Father r Stepfather r Legal Guardian

r Mother rStepmother r Foster Parent

Other(pleaseindicaterelaonship):

Address: rAddressisthesameasstudent’saddressabove

Street Apt #

City State Zip

Parent/Guardian’s preferred language of communicaon?

r English r Spanish rAmharic r Arabic rOther(pleasespecify)

LastName: FirstName: r Male rFemale

Employer:

WorkAddress:

WorkPhone:( ) - Ext:

STUDENT INFORMATION

PARENT/GUARDIAN INFORMATION

Birth Cercate: r Yes rNo BirthCercate#:

Revised 3/2015 Communicaons Oce dnb

Physician’s Name: Phone:( ) -

Parent/Guardian Signature: Date:

Ifwearenotabletocontactyouorthephysicianlistedabove,dowehaveyourpermissiontotakeyourchildtotheemergencyroomofthenearest

hospital,atyourexpense,anddowefurtherhaveyourauthorizaonforthehospitalanditsmedicalstatoprovidesuchtreatmentasaphysician

deemsnecessaryforthewell-beingofyourchild? r Yes r No

By signing this form I am verifying that the informaon contained herein is correct.

Parent/GuardianSignature: Date:

During the year before kindergarten, my child

aended (choose one):

Home-Based Child Care

r Childcareproviderinmyhome

r Childcareproviderintheirhome

r Parent/Relave

Alexandria City Public Schools

r VirginiaPreschoolIniave(VPI)4-year-oldprogram

r EarlyChildhoodSpecialEducaon

r Preschoolers Learning Together

Other Program

r Head Start

r ChildandFamilyNetworkCenter

r ChildCareCenter(fullday,fullyear)

Name:

r Half-DayProgram(preschool)

Name:

Please check if your child has any medical condions:

r Allergy

r HearingImpaired

r Othermentalorphysicalimpairment(pleasespecify)

r Asthma

r Seizure Disorder

r Diabetes r Heart Diseaser Ausm

r VisualImpairment(includingwearsglassesorcontacts)

Name Birth Date Sex School

Student ID School ID Sch/Res

A/Permit

Code

Address/Transfer

Permit Veried

Grade Entry Code Entry Date Oce Vericaon/Signature

Does your child have a current IEP for Special Educaon services or 504 Plan? r Yes r No

If Yes, has documentaon been provided to the school? r Yes r No

Emergency Contact #1 (Other than Parent/Guardian):

Name:

Address: Street Apt #

City State Zip

HomePhone:( ) -  CellPhone:( ) -

WorkPhone:( ) -

Relaonshiptostudent:

Emergency Contact #2 (Other than Parent/Guardian):

Name:

Address: Street Apt #

City State Zip

HomePhone:( ) -  CellPhone:( ) -

WorkPhone:( ) -

Relaonshiptostudent:

STUDENT BACKGROUND

OTHER CHILDREN IN THE FAMILY

FOR OFFICE USE ONLY

EMERGENCY CONTACTS PRE-KINDERGARTEN EXPERIENCE