Fillable Printable Student Registration Form - Alexandria City Public Schools
Fillable Printable Student Registration Form - Alexandria City Public Schools

Student Registration Form - Alexandria City Public Schools

Revised 3/2015 Communicaons Oce dnb
STUDENT REGISTRATION FORM
•
Alexandria City Public Schools
Student’s Last Name:First Name:Middle Name:
Student Address: Street Apt #
City State Zip
rMalerFemaleDate of Birth: Mo: Day: Year:Country of Birth:Grade:
*Is this student Hispanic or Lano? (choose only one)
*What is the student’s race? (choose one or more)
Last School Aended:r Public r Private
Address: City State Zip
If not an Alexandria City school, has student EVER aended Alexandria City Public Schools?r Yesr 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?
rNo,notHispanicorLanorYes,HispanicorLano(personofCuban,Mexican,PuertoRican,SouthAmerican,
CentralAmerican,orotherSpanishcultureororigin,regardlessofrace)
rAmericanIndian/Alaskan
r Asian
r Spanish rAmharicr Arabic rOther(pleasespecify)
rBlackorAfricanAmerican
rNaveHawaiianorOtherPacicIslander
rWhite(apersonhavingoriginsinanyoftheoriginal
peoplesofEurope,theMiddleEastorNorthAfrica)
Parent/Guardian:
Is the City of Alexandria your legal residence? r Yesr No
IfNo,hasanexcepontopolicybeenapproved?r Yesr No
Parent/Guardian #1:
HomePhone:()- CellPhone:()- EmailAddress:
r Father r Stepfather r Legal Guardian
r Mother rStepmotherr Foster Parent
Other(pleaseindicaterelaonship):
Address: rAddressisthesameasstudent’saddressabove
Street Apt #
City State Zip
Parent/Guardian’s preferred language of communicaon?
r English r Spanish rAmharicr Arabic rOther(pleasespecify)
LastName:FirstName:r Male rFemale
Employer:
WorkAddress:
WorkPhone:()- Ext:
Parent/Guardian #2:
HomePhone:()- CellPhone:()- EmailAddress:
r Father r Stepfather r Legal Guardian
r Mother rStepmotherr Foster Parent
Other(pleaseindicaterelaonship):
Address: rAddressisthesameasstudent’saddressabove
Street Apt #
City State Zip
Parent/Guardian’s preferred language of communicaon?
r English r Spanish rAmharicr Arabic rOther(pleasespecify)
LastName:FirstName:r Male rFemale
Employer:
WorkAddress:
WorkPhone:()- Ext:
STUDENT INFORMATION
PARENT/GUARDIAN INFORMATION
Birth Cercate:r YesrNoBirthCercate#:

Revised 3/2015 Communicaons Oce dnb
Physician’s Name:Phone:()-
Parent/Guardian Signature:Date:
Ifwearenotabletocontactyouorthephysicianlistedabove,dowehaveyourpermissiontotakeyourchildtotheemergencyroomofthenearest
hospital,atyourexpense,anddowefurtherhaveyourauthorizaonforthehospitalanditsmedicalstatoprovidesuchtreatmentasaphysician
deemsnecessaryforthewell-beingofyourchild?rYesrNo
By signing this form I am verifying that the informaon contained herein is correct.
Parent/GuardianSignature: Date:
During the year before kindergarten, my child
aended (choose one):
Home-Based Child Care
rChildcareproviderinmyhome
rChildcareproviderintheirhome
rParent/Relave
Alexandria City Public Schools
rVirginiaPreschoolIniave(VPI)4-year-oldprogram
rEarlyChildhoodSpecialEducaon
r Preschoolers Learning Together
Other Program
r Head Start
rChildandFamilyNetworkCenter
rChildCareCenter(fullday,fullyear)
Name:
rHalf-DayProgram(preschool)
Name:
Please check if your child has any medical condions:
r Allergy
rHearingImpaired
rOthermentalorphysicalimpairment(pleasespecify)
rAsthma
r Seizure Disorder
r DiabetesrHeart DiseaserAusm
rVisualImpairment(includingwearsglassesorcontacts)
NameBirth DateSexSchool
1.
2.
3.
4.
Student IDSchool IDSch/Res
A/Permit
Code
Address/Transfer
Permit Veried
GradeEntry CodeEntry DateOce Vericaon/Signature
Does your child have a current IEP for Special Educaon services or 504 Plan?r Yesr No
If Yes, has documentaon been provided to the school?r Yesr No
Emergency Contact #1 (Other than Parent/Guardian):
Name:
Address: Street Apt #
City State Zip
HomePhone:()- CellPhone:()-
WorkPhone:()-
Relaonshiptostudent:
Emergency Contact #2 (Other than Parent/Guardian):
Name:
Address: Street Apt #
City State Zip
HomePhone:()- CellPhone:()-
WorkPhone:()-
Relaonshiptostudent:
STUDENT BACKGROUND
OTHER CHILDREN IN THE FAMILY
FOR OFFICE USE ONLY
EMERGENCY CONTACTSPRE-KINDERGARTEN EXPERIENCE