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Winthrop Middle School Enrollment Form
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Previous School
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Please list the name of the previous school attended.  Please also include a location and if you have it, a contact number.  If this is a new enrollment, for a student never being in school before, state New Enrollment
Is the student currently under an expulsion from another school?
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Student Last Name *
Student First Name *
Student Middle Name *
Date of Birth *
MM
/
DD
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YYYY
Place of Birth (City/State/Country)
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Gender *
Home Phone Number *
This is the number that will get all automated calls from the school
Alternate Home Phone Number
This number will also get automated calls from the school, if you'd like a second number listed
Grade Level *
Military Connection *
Home Language *
Does your student receive English-Language Learner Services?
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Residency: I Certify on the penalty of perjury that my the information contained herein is true and correct and I actually live with the student named above in the town of Winthrop at the address listed above. I will provide TWO proofs of residency ie. (Central Maine Power, Spectrum, Winthrop Utilities Bill, Insurance Card, Tax Bill, Car registration, Drivers License, Consolidated Communications) Proof of residency is required prior to student starting school.
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Has the student moved into the district for agricultural reasons? (Migrant Worker)
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Does your student have a 504 plan
Clear selection
Does your student receive gifted and talented instruction?
Clear selection
Home Schooled *
You should answer yes if you are keeping home based education and enrolling in the school part time
Does your student receive Special Education services?
 *
Special Education
If your student has an IEP please select the disability
Clear selection
Sibling's Name(s)
Please list siblings who will also be in school in the district
Home Address
Please list siblings who will also be in school in the district
Home Street, Apt/Suite *
Home City *
Home State *
Home Zip Code *
Mailing Address
Enter your mailing address if different than your home address, or leave blank if it's the same
Mailing Street, Apt/Suite
Mailing City
 Mailing State
Mailing Zip Code
Demographic Information
Is the student Hispanic or Latino? *
Federal Reporting Ethnicity *
These are the list the federal government requires us to use.  Please select the appropriate box or boxes.
Required
Please chose which of the following situations the student currently resides in (you can choose more than one):
 *
These are the list the federal government requires us to use.  Please select the appropriate box or boxes.
Required
if you are living in shared housing, please check all of the following reasons that apply:
These are the list the federal government requires us to use.  Please select the appropriate box or boxes.
Student Lives With *
Mother's Name *
First, Last MI
Mother's Day Phone
Mother's Work Phone
Mother's Home Phone
Mother's Cell Phone
Mother's Employer
Mother Permissions
Mother's Marital Status
Clear selection
Mother's Email Address
Mother's Address
If different from the student
Father's Name *
First, Last MI
Father's Day Phone
Father's Work Phone
Father's Home Phone
Father's Cell Phone
Father's Employer
Father Permissions
Clear selection
Father's Marital Status
Clear selection
Father's Email Address
Father's Address
If different from the student
Other Guardian's Name
Guardian's Day Phone
Guardian's Home Phone
Guardian's Cell Phone
Father's Significant Other
Ignore this section if it isn't applicable
Father's SO Name
Father's SO Day Phone
Father's SO Home Phone
Father's SO Cell Phone
Father's SO Permissions
Clear selection
Mother's Significant Other
Ignore this section if it isn't applicable
Mother's SO Name
Mother's SO Day Phone
Mother's SO Home Phone
Mother's SO Cell Phone
Mother's SO Permissions
Clear selection
Transportation
If student is riding school bus please list AM and PM pick up and drop off addresses.
Emergency/Medical Contacts
These need to be someone other than the parents listed above, as these will be used when parents cannot be reached
Contact 1 Name *
Contact 1 Relationship *
Relationship to the student
Contact 1 Phone Number *
Contact 2 Name
Contact 2 Relationship
Relationship to the student
Contact 2 Phone Number
Contact 3 Name
Contact 3 Relationship 
Relationship to the student
Contact 3 Phone Number
Daycare Name and Phone Number
Doctor's Name *
Doctor's Phone *
Dentist's Name
Dentist's Phone
Special Medication Considerations
List anything the school needs to be made aware of here with medical conditions
Allergies
Other Alerts (Court Orders) Please Provide Court Order to Appropriate School (if your student has a court order pertaining to them)
I give my permission for my for my child to be interviewed and/or photographed for Television and or a Newspaper
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I authorize the school nurse is authorized personnel to administer OTC (Over The Counter) and Emergency Med/Tx per standing orders
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I give my permission for my for my child's picture to be posted on the schools district website or distribute pictures via email/internet?
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