Mosinee 4K Enrollment for Fall 2017
The person filling this from out will need to know or gather the following information:
1) student's birth information
2) mother , father and emergency contact's address, email, phone numbers
3) doctor and dentist name and number
4) 4K and bus transportation choices
5) health, behavioral, schooling history
6) names of student's medications
Person completing this form: *
Your answer
Fill in the Student Information below
Student's Legal Last Name:
Your answer
Student's Legal First Name:
Your answer
Student's Legal Middle Name:
(leave blank if no middle name)
Your answer
Sex:
Is this student Hispanic or Latino?
(choose only one)
Student's Race:
(choose at least one)
Complete Mailing Address:
Include city, state and zip code
Your answer
Birth Date:
MM
/
DD
/
YYYY
Birth City:
Your answer
Birth County:
(ex. Marathon, Portage, Lincoln, Wood)
Your answer
Birth State:
(ex. Wisconsin, Illinois, Minnesota)
Your answer
Birth Country:
(ex. USA, Canada, Mexico)
Your answer
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