FIRST NAME:

MIDDLE NAME:

LAST NAME:

RACE Please answer the following in accordance with standards issued by the US Department of Education.

PRIMARY RACE (Please select only ONE)

• American Indian or Alaska Native (A person having origins in any of the original peoples of North and South America, including Central America, and who maintains tribal affiliation or community attachment)

• Asian (A person having origins in any of the original peoples of Far East, Southeast Asia, or the Indian                                                                                       subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam)  

• Black or African American (A person having origins in any of the black racial groups of Africa)

• Native Hawaiian or Other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands)

• White (A person having origins in any of the original peoples of Europe, Middle East or North Africa)

ADDITIONAL RACES (check all that apply):

___American Indian/Alaska Native                         ___Asia          ___Black

___Native Hawaiian/Other Pacific Islander         ___White

Student Physical/911 Address

Address:__________________________________

City:________________________________________

State:_____________ Zip Code:_________________

Student Mailing Address

• Mailing Address is same as Physical/911 Address

Address:_____________________________________

City:________________________________________

State:_____________ Zip Code:_________________

TRAVEL TO SCHOOL (Please check one)

❑ Bus (Bus Number_______)

❑ Drives Self

❑ Parent/ Guardian (includes walkers etc.)

❑ District Paid Transportation

Distance from school in miles one way? _________

TRAVEL FROM SCHOOL (Please check one)

❑ Bus (Bus Number_______)

❑ Drives Self

❑ Parent/ Guardian (includes walkers etc.)

❑ District Paid Transportation

City of Birth:________________           State of Birth________________    

Birth Certificate #:__________________________        Is this student a twin, triplet, quadruplet, etc.?     ❑ Yes    ❑ No

Is this student a dependent of an active or reserve member of a branch of the United States Armed Services?                            ❑ Yes    ❑  No       If yes, please specify which branch below:

❑ Active Duty-US Army                      ❑ Active Duty-US Marines                     ❑ Active US Coast Guard

❑Reserves- US Army                            ❑ Reserves- US Marines                         ❑ National Guard- US Army

❑ Active Duty US Air Force                ❑ Active Duty- US Navy                          ❑ National Guard- US Air Force

❑ Reserves- US Air Force                    ❑ Reserves- US Navy                               ❑ Parents serve in multiple branches

Parent/Guardian 1

Name:_______________________________________________

Relationship to Student:______________________________

Language:___________________________________________

❑ Student Primarily Resides with this Guardian

Home Phone: ______________   Cell Phone:______________

**Alert Phone:________________________________________

(check one)   ❑ TEXT    ❑ VOICE    ❑ BOTH

*Preferred alert phone # used to receive district’s automated calls about school closings and other important information.

❑ Mailing address is same as Student Mailing Address

Mailing Address:__________________________________

City:_____________________________________________

State:___________    Zip Code:_______________________

Email:____________________________________________

Employer:_______________________________________

Parent/Guardian 2

Name:________________________________________

Relationship to Student:_______________________

Language:_____________________________________

❑ Student Primarily Resides with this Guardian

Home Phone: ______________  Cell Phone:_____________

**Alert Phone:_____________________________________

(check one)   ❑ TEXT    ❑ VOICE    ❑ BOTH

*Preferred alert phone # used to receive district’s automated calls about school closings and other important information.

❑ Mailing address is same as Student Mailing Address

Mailing Address:______________________________

City:__________________________________________

State:_________    Zip Code:_____________________

Email:________________________________________

Employer:____________________________________

Does Student have a 504 Plan or IEP?    ❑  Yes    ❑  No     If so specify___________

Does student participate in the Gifted and Talented Program or Title I?     ❑  Yes    ❑  No   if so specify____________

If student is in 7th-12th grade, will they be participating in the “Smart Core” Curriculum?  ❑ Yes   ❑ No

Pre-School Participation: (circle one)

1. Arkansas Better Chance                     H- Headstart                                                                      O- Other

E-    Even Start                                               NA- Not Applicable                                                           P- Private Pre School

EC- Early Childhood                                   C- 21st Century Community Learning Center          PS- Pubic School Pre-K

Contact Order

Name

Relationship to Child

Phone Number

Phone Type

(Home, Cell, Work)

1

2

3

4

Physician:_________________________________________________                                                            Physician Phone: _____________________________________

Please list any medical concerns and/or medications for this child:__________________________________________________________________________