Student Registration Form Fields marked with an * are required HTML Student Personal Data Student Last Name * Student First Name * Student Middle Name Birth Date * Sex * Male Female Age Group * Infant Toddlers Twos Threes Pre-K Transistional-K Kindergarten Divider HTML Copy Medical Doctor * Doctor Phone Number * Dentist * Dentist Phone Number * Specialist Specialist Phone Number Insurance Company * Insurance Policy # * Food Allergies Known Medical Conditions If your child is currently taking medication that would be given during school hours, please list them here Other Allergies Special Diet Restrictions Current Immunization Records Provided? Yes No Date of Last Physical Other Notes About Student Divider HTML Copy Copy Parent 1 Information (required) Parent 1 Last Name * Parent 1 First Name * Mother or Father? * Mother Father Guardian? * Yes No Parent 1 Address * City * State * - Select State - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Washington DC Zip * Parent 1 Home Phone * Parent 1 Cell Phone * Parent 1 Driver's License # * Parent 1 Last four digits of SSN * Parent 1 Email * Parent 1 Employer * Parent 1 Employer Phone * Parent 1 Employer Address * City * State * - Select State - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Washington DC Zip * HTML Copy Copy Copy Parent 2 Information (optional) Parent 2 Last Name Parent 2 First Name Mother or Father? Mother Father Guardian? Yes No Parent 2 Address City State - Select State - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Washington DC Zip Parent 2 Home Phone Parent 2 Cell Phone Parent 2 Driver's License # Parent 2 Last four digits of SSN Parent 2 Email Parent 2 Employer Parent 2 Employer Phone Parent 2 Employer Address City State - Select State - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Washington DC Zip Divider HTML Emergency InformationAuthorized Pickup Persons (other than parent) HTML Copy Authorized Pickup Person 1 Pickup Person 1 Name Relationship to student Pickup Person 1 Phone Pickup Person 1 Driver's License Number Pickup Person 1 Address HTML Copy Copy Authorized Pickup Person 2 Pickup Person 2 Name Relationship to student Pickup Person 2 Phone Pickup Person 2 Driver's License Number Pickup Person 2 Address HTML Copy Copy Copy Authorized Pickup Person 3 Pickup Person 3 Name Relationship to student Pickup Person 3 Phone Pickup Person 3 Driver's License Number Pickup Person 3 Address Divider HTML Educational Information Name of Former Preschool/Daycare Former Preschool/Daycare Address Former Preschool/Daycare Phone Does your child have any special learning challenges that the school should be aware of? If yes, please explain. Has your child ever been suspended or asked to withdraw from school? If yes, please explain. HTML After submitting this registration, you will need to print out and sign the other forms listed on the forms page. We will also need a copy of Mother and Father’s driver’s license. For tax purposes, we must also have at least one parent’s social security number. If you are a human seeing this field, please leave it empty.
