. PORTERVILLE UNIFIED SCHOOL DISTRICT ‘School Year: STUDENT REGISTRATION FORM GRADES 9-12 OFFICE USE ONLY: ‘Counsea ‘Perm 1D: ter date: Bait date: Tter/atra: PLEASE COMPLETE THE FOLLOWING INFORMATION: ‘Student Legal Last Name First Name Middle Neme Grade Gender Birthdate Correspondence Language (Circe One) ‘Student Phone English Spanish PRIMARY HOUSEHOLD INFORMATION: Ling Wik 1-Both Parents 2-Mother Only 3-Father Only 4-Foster 5-Caregiver 6-Guardian 7-MotherStepfather 8-Fathee/Stepmother __9-Other, PARENT/GUARDIAN Fi Parens/Guardian Name ‘Cell Phone ‘Email address Work Phoneft Mailing Address City Zip Code Resident Address (if different than mailing address) City Zip Code PARENT/GUARDIAN #2 Paren/Guardian Name el Phone ‘Email address [Work Phonot Mailing Address City Zip Code Resident Address (i/diférent than mailing address) Ci Zip Code LIST ALL OTHERS LIVING IN THE HOME, ‘Name and Relationship Birthdate ] Gender ] Grade ‘School 1s Parent/Guardian an active member of the Armed Forces? (Ex: Army, Navy, Alr Force, Marines, Coast Guard, National Guard) Yeo No ee EMERGENCY CONTACT INFORMATION List two local persons (other shan yoursel usually available student if he/she becomes ill or injured and you cannot be daring the school dey who have apresd to care for and provide wansporation for ‘teached. We attempt to contact parents first. e ne Name eaonhip Phone = to Student | ie Tans Talal Fane — ‘to Student : ‘Parent Education Level: (Please check one area for each parent) - ‘Mother: Not a high school graduate __ High school graduate _ Some college _ Colle Nota h ae —Some college College graduate __Graduate/post Father, Nota high school graduate High school graduate Some college College graduate _ Graduate/post oa eee eee PREVIOUS 5 \CHOOL INFORMATION Last School Atended ‘Grade ‘Adress of Former School, City, State, Has your student previously attended a school in Porterville Unified School District? (circle one) Yes No Ifyes: School Attended: Years) Attended: Grate: Has your student ever received services in any of the following? (circle all that apply) Speech & Language GATE Special Education Section S04 Migrant Has student ever been expelled? —Yes_-No__ If yes, what grade level? Has student ever been retained? Yes No _Ifyes, what gradelevel?. Has student ever been referred to Student Attendance Review Board (SARB)? (circle one) Yes No ETHNICITY: Select ONE group which the student most | RACE: Mark ALL groups with which the tadeat identifies closely Identifes: American Indian or Alaska Native 0 Japanese (0 Hispanie/Lating 1 Asian Indian Korean (Black or African Amertean Laotian {Not Hispanic/Latino O.Cambodian 1 Vietoamese Chinese Samoan O Filipino O Tahitian O Guamantan 1 Other Asian O Hawaiian 0 Other Paciic Wtander O Hmoag OWhite 1. ACTIVITY PERMIT: ‘3. PARENTSRIGHTS: | hereby grant permission for my student to attend the following ‘The law requires that parents be given 2 copy of certain Education Code activities. These activities wil be under the supervision of and subject to ff sections specifying parents” rights. These were sent home with your student ‘the Jurisdleton of the school ditrct or tchool teacher. ‘or given to you, Your signature below signifies that you have received lease chesk appropriately. ‘hem. ‘Yeu!No fl YOUR SIGNATURE CERTIFIES TO THESE THREE ITEMS. FiddTrips 0 0 ‘Other School Sponsored Activites 0 0. Date 7%, INSURANCE: ‘All students who participate in after school athletic programs mast have ‘accident insurance coverage. Do you havea personal accident insurance policy for your student? Yes ONo Parents may purchase school insurance for thelr student, Please ‘contact the school office for detalls. HEALTH INFORMATION Does your student take any prescription medication on a daily basis? Yes No Ifyes, expl Does your student have any problems with hearing? Yes No _Ifyes, explain: Does your student wear glasses or contact lenses? Yes. «-No.__‘Ifyes, which? 1s your student allergic to any insect, food or drugs? Yes No _ If yes, explain: ‘Does your student have any chronic health problems? Yes No Ifyes, explain: Ti case of serious injury or ness and I cannot be reached, you have my permission to take my student to SIERRA VIEW DISTRICT HOSPITAL for medical emergency treatment or care. fPareat or Gus ian Signatur Revised: 717719