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Records Request - NEW STUDENTS ONLY
Eureka Springs High School
Tricia Rusterholz (trusterholz@es.k12.ar.us)
2 Lake Lucerne
Eureka Springs, AR 72632
479-253-8875 (phone)
479-253-8390 (fax)
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Email *
Student Name - Last *
Student Name - First *
Date of Birth - ex 00-00-0000 *
Grade Enrolling In *
Previous School *
Address Previous School-Street, City, State, Zip Code *
Phone # of Previous School-ex: 000-000-0000 *
Fax # of Previous School-ex: 000-000-0000 *
Has this student been expelled or involved in expulsion proceedings? *
Does the student have an IEP *
Does the student have a 504 *
Parent Signature - Typing your name is equivalent to signing *
Date *
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