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

•

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 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 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?

rNo,notHispanicorLanor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 Yesr No

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

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 DiabetesrHeart DiseaserAusm

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

NameBirth DateSexSchool

Student IDSchool IDSch/Res

A/Permit

Code

Address/Transfer

Permit Veried

GradeEntry CodeEntry DateOce Vericaon/Signature

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

If Yes, has documentaon been provided to the school?r Yesr 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 CONTACTSPRE-KINDERGARTEN EXPERIENCE