School Year
Basic Student Information - Part 1
Last Name First Name Middle Other
Sex Male Female Date of Birth Age Birthplace
School Grade Social Security Number
Transferred From Address:
NOT born in any State*
Has NOT been attending one or more schools in any one or more states* for more than 3 full academic years.
If NO, how many years at the point of enrollment
*State refers to the 50 U.S. States, the District of Columbia, and the Commonwealth of Puerto Rico)
Home School:
Grade Level:
911 Address
City State/Zip
Mailing Address
City State/Zip
Student Home Phone # Listed Unlisted
Transport by Bus: If YES, Bus # AM PM Special Medical Need
List Siblings
Is home language English Native Language
Hispanic Race Options (Check all that apply)
Parent/Guardian Information - Part 2
Call Order
Last Name First Name Middle Relationship
Home Phone # Cell Phone #
911 Address
City State/Zip:
Mailing Address if different than above
City State/Zip
Employer Name:
Employer Work Phone# Ext.
Occupation Cell Phone # Ext
Pager # Ext. Email Address
I require translator services to communicate
Parent/Guardian Information - Part 3
Call Order
Last Name First Name Middle Relationship
Home Phone # Cell Phone #
911 Address
City State/Zip:
Mailing Address if different than above
City State/Zip
Employer Work Phone# Ext.
Occupation Cell Phone # Ext
Pager # Ext. Email Address
I require translator services to communicate
Emergency Contact Information Other than Parent/Guardian for Immediate Pick-Up from School - Part 4
Call Order
Last Name First Name Middle Relationship
Home Phone # Cell Phone #
911 Address
City State/Zip:
Mailing Address if different than above
City State/Zip
Employer Work Phone# Ext.
Occupation Cell Phone # Ext
Pager # Ext. Email Address
I require translator services to communicate
CALL ORDER INDICATES THE ORDER IN WHICH TO CONTACT PARENTS/GUARDIANS IN THE EVENT OF AN EMERGENCY
The questionnaire in this section is intended to address the McKinney-Vento Act 42 U.S.C. 11435. The answers to this residency information will help determine services the student may be eligible to receive.
1. Is your current address a temporary living arrangement?
2. If YES, is this temporary living arrangement due to loss of housing or economic hardship?
Signature of Parent/Guardian Date
By checking this box, I verify my identity and that the information was entered accurately
Student School
In case the child for whom I am responsible becomes seriously ill or injured at school, please take them to . The physician and hospital are hereby authorized to render such treatment as may be deemed necessary in an emergency for the health of this child.
Home Phone # Work Phone # Cell Phone # Pager # Email Address
Name of Physician Physician Phone #
Physician's Address
Check the box next to any conditions the above student has:
1. Heart Defect
2. Diabetes
3. Convulsions/Seizure Disorder
4. Cerebral Palsy
5. Visual Impairment
a. Corrective Glasses
6. Hearing Impairment
a. Hearing Aid
8 Orthopedic Impairment
a. Wears Prosthesis
9. Scoliosis
10, Behavioral Disorders
12. Gastro/Intestinal Disorder
11. Asthma
14. Allergies
a. Seasonal
b. Food
c. Bee Sting
15. Nasal/Respiratory Disorder
16. Limited Activities
17 Premature Birth
18. Other
Signature Parent or Guardian Date
By checking this box, I verify my identity and that the information was entered accurately
I AM 18 YEAR OF AGE OR WILL BE 18 YEARS OF AGE DURING THE SCHOOL YEAR AND HEREBY GRANT MY CONSENT FOR JEFFERSON COUNTY SCHOOLS TO CONTACT ANY LEGAL GUARDIAN IN CASE OF EMERGENCY
Student's Signature: Date
By checking this box, I verify my identity and that the information was entered accurately
Security Measure