Scribd
Upload
48 views3 pages

Untitled Document

This document is an enrollment form for a school district. It requests information such as the student's name, date of birth, address, grade, parents' or guardians' names and contact information. It also asks for emergency contacts, transportation details, any custody arrangements, and a parent signature agreeing to disclose the student's social security number which is voluntary. Special needs, siblings enrolled in the district, and pre-school attendance are also collected. The form is used to register a student for the upcoming school year.

Uploaded by

api-393067124
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
48 views3 pages

Untitled Document

This document is an enrollment form for a school district. It requests information such as the student's name, date of birth, address, grade, parents' or guardians' names and contact information. It also asks for emergency contacts, transportation details, any custody arrangements, and a parent signature agreeing to disclose the student's social security number which is voluntary. Special needs, siblings enrolled in the district, and pre-school attendance are also collected. The form is used to register a student for the upcoming school year.

Uploaded by

api-393067124
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 3

ENROLLMENT FORM

UNIFIED PCA CHURCH SCHOOL DISTRICT


610 14th Avenue South
Phenix City, AL 36869
706-304-6091

PAGE 1
DATE​_______________​SCHOOL​_______________________​GRADE​_______
LAST NAME​_____________​FIRST NAME​______________​MIDDLE NAME​____________
DATE OF BIRTH​____________​AGE​_____​SEX​_____​HOME PHONE​_________________
STREET ADDRESS​_______________​CITY​____________​STATE​_______​ZIP CODE​_____
MAILING ADDRESS​_______________​CITY​____________​STATE​_________​ZIP CODE​____
CHILD LIVES WITH: ​(​circle one) PARENTS MOTHER FATHER
GUARDIAN:RELATION__________________
*​SOCIAL SECURITY NUMBER​(voluntary)______________________

PARENT(S)/GUARDIAN NAME: *If guardian, provide school with a copy of guardianship


papers.**

MOTHER/GUARDIAN D.O.B. ADDRESS

name________________________

EMAIL ADDRESS CELL PHONE

EMPLOYER WORK PHONE

FATHER/GUARDIAN D.O.B. ADDRESS


name_________________________

EMAIL ADDRESS CELL PHONE

EMPLOYER WORK PHONE

SPECIAL INFORMATION ABOUT


CUSTODY​__________________________________________________________________________________
_____________________________________________________________________________________________

THESE PEOPLE ARE ALLOWED TO CHECK MY CHILD OUT OF SCHOOL(​in accordance with the school’s check
out policy)

1. D.O.B. PHONE

2. D.O.B. PHONE

3. D.O.B. PHONE

EMERGENCY CONTACTS:​ (Please list numbers other than your own...VERY IMPORTANT!!!!!!!!)
EMERGENCY #1 EMERGENCY #2
NAME______________________ NAME__________________
D.O.B._________________________ D.O.B.__________________
RELATION_____________________ RELATION_______________
PHONE________________________ PHONE_________________

NAME & ADDRESS OF FORMER SCHOOL: ​(if applicable)


_________________________________________ ___________________________________________
_________________________________________ ___________________________________________

PAGE 2
STUDENT____________________________
SPECIAL NEEDS:​(circle if applicable) SPECIAL EDUCATION SPEECH/LANGUAGE 504 PLAN GIFTED

TRANSPORTATION:​(circle one)
CAR RIDER WALKER BUS RIDER

EARLY DISMISSAL INFORMATION:


____​My child will ride the bus home as usual. I understand that buses will be leaving early and I will make
arrangements for a responsible person to be at the normal destination.
____My child will be a car rider and will be picked up by one of the guardians or persons listed as an
emergency contact on this form. My child is not to ride the bus home in the event of school closing early.
LIST SCHOOL AGE SIBLINGS:
NAME
___________________________________
___________________________________
___________________________________
___________________________________

GRADE
_______________
_______________
_______________
_______________

KINDERGARTEN ENROLLEES ONLY:


ATTENDED PRE-SCHOOL YES NO

NAME OF PRE-SCHOOL

PARENT SIGNATURE_________________________________________
PARENT PRINT______________________________________________
DATE________________________
*Disclosure of your child’s social security number (SSN) is voluntary. If you elect not to provide a SSN, a
temporary identification number will be generated and utilized instead. Your child’s SSN is being requested
for use in conjunction with enrollment in school as provided in Ala. Admin. Code ​§290-3-1-.02(2)(b)(2). It will

be used as a means of identification in the statewide student management systems.

You might also like