Enrollment Forms
Student Name
Your answer
Grade
Your answer
Birth Date
MM
/
DD
/
YYYY
Physical Address
Your answer
Mailing Address (if different than physical)
Your answer
Custodial Parent/Guardian
Your answer
Relationship to Student
Your answer
Address (if different from student)
Your answer
Phone (H)
Your answer
Phone (C)
Your answer
Parents Email
Your answer
Employer
Your answer
Work Phone
Your answer
Second Parent/Guardian
Your answer
Relationship to student
Your answer
Address (if different from student)
Your answer
Phone (H)
Your answer
Phone (C)
Your answer
Parent's Email
Your answer
Employer
Your answer
Work Phone
Your answer
Student Emergency Health Information
Physician's Name and Phone Number
Your answer
Dentist's Name and Phone Number
Your answer
Please list names and phone numbers or persons who may be contacted in the event a parent can not be reached. Only those listed below will be permitted to pick up your child in case of illness or emergency.
Name and Number
Your answer
Name and Number
Your answer
Name and Number of Insurance
Your answer
Current Health Issues (such as diabetes, seizure, asthma, etc.
Your answer
Health History (include past surgeries, serious illnesses, head injuries, etc.)
Your answer
Medications (home)
Your answer
Medications (school)
Your answer
Allergies
Your answer
Reaction
Your answer
EpiPen
Restrictions: Describe any necessary restrictions or limitations.
Your answer
Does your child wear glasses?
If so, Eye Doctor?
Your answer
Describe any eye/vision problems
Your answer
Any hearing problems?
If so, please describe
Your answer
By typing your name and the date below, you are electronically signing that you give the school nurse permission to share the above information with other school personnel or Emergency Medical Services on a "need to know" basis.
Your answer
Parent/Guardian Name
Your answer
Date
MM
/
DD
/
YYYY
Early Dismissal
At times, school will be dismissed early because of emergency situations such as inclement weather. Since the telephone lines must remain open and we have too many students to call each home, we require that you prepare in advance an Emergency Dismissal Plan for your child. Please fill out the following information instructing your child's teacher what to do in case of early dismissal.
Student
Your answer
Teacher
Your answer
Home Phone
Your answer
Early dismissal instructions (ride bus, daycare, etc.):
Your answer
Name and number for emergency contacts:
Your answer
Contact #2
Your answer
Contact #3
Your answer
Enrollment Notification of Pest Management Services
Kanawha County Schools, in keeping with our commitment to provide a safe school environment and to comply with state law, is hereby providing notice that an IPM (Integrated Pest Management) program is being implemented in all Kanawha County Schools.
Please provide the information below if you want to request a 24-hour notice prior to the application of any pesticides. The application of pesticides will be done judiciously and in all cases the least hazardous materials will be used.
Would you like to be notified of any application of pesticides?
Photographic Release
Chamberlain maintains a website, chamberlain.kana.k12.wv.us, and a Facebook and Twitter page. We upload videos and post pictures daily of the exciting things that are going on. Please indicate below if you give us permission to use your child in photographs and/or videos, billboard advertisements, Social Media Channels, Website, etc., as needed by Kanawha County Schools.
Please choose one:
Permission to Walk Home From School
As the parent/legal guardian of a Chamberlain Elementary student, I understand the following guidelines apply to students who walk home from school:
1. Students who walk home will be dismissed at 3:00 pm.
2. Students are to go directly home. Under no circumstances are they permitted to stop at places of business or other's homes or vehicles.
3. School rules apply until the student is in his/her own home. Continued reports of unsafe or inappropriate behavior may result in the loss of this privilege or other disciplinary action.
4. Students are to learn and obey pedestrian traffic rules.
5. Students will be given directions as to personal safety precautions by parents and school personnel.
Is your child to walk home from school?
By typing my name below, I am stating that I have read and understand this form in its entirety.
Parent Name
Your answer
Date
MM
/
DD
/
YYYY
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