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Lindale ECC New Student Enrollment Form
Please complete this form and record your digital signature at the bottom of the form.
Student's Last Name *
Your answer
Student's First Name *
Your answer
Student's Middle Name *
Your answer
Name Suffix
Student Date of Birth: *
mm-dd-yyyy
Your answer
Grade *
Gender *
Student Social Security Number *
xxx-xx-xxxx
Your answer
Hispanic/Latino Ethnicity *
Race *
What is student's race? (Choose one or more)
Required
What language is spoken in your home most of the time? *
Your answer
What language does your child speak most of the time? *
Your answer
Today's Date: *
MM
/
DD
/
YYYY
Custodial Parent or Guardian (1) First & Last Name: *
Household 1
Your answer
Relationship to student: *
Your answer
Custodial Parent or Guardian (1) Gender *
Household 1
Custodial Parent or Guardian (1) Date of Birth *
Household 1- mm-dd-yyyy
Your answer
Custodial Parent or Guardian (1) Driver's License Number
Household 1
Your answer
Custodial Parent or Guardian (1)- Primary Phone Number *
Household 1 xxx-xxx-xxxx
Your answer
Custodial Parent or Guardian (1) - Cell Phone Number
Household 1 xxx-xxx-xxxx
Your answer
Custodial Parent or Guardian (1) - Work Phone Number
Household 1 xxx-xxx-xxxx
Your answer
Custodial Parent or Guardian (1) Email
Household 1
Your answer
Custodial Parent or Guardian (1)Physical Address *
Household 1 - Number & Street
Your answer
Custodial Parent or Guardian (1) City/Town *
Household 1
Your answer
Custodial Parent or Guardian (1) Zip Code *
Household 1
Your answer
Custodial Parent or Guardian (1) Mailing Address
If different from physical address. Number, Street, Town, State
Your answer
Guardian (2) First & Last Name:
Household 1
Your answer
Guardian (2) Relationship to student:
Household 1
Your answer
Guardian (2) - Cell Phone Number
Household 1 xxx-xxx-xxxx
Your answer
Guardian (2) Email
Household 1
Your answer
Custody Information
If parents are divorced or separated please provide the following - copy of court documentation is required.
Special Conditions:
Your answer
Guardian First & Last Name
Household 2 - if parents are divorced or separated, please provide the following.
Your answer
Guardian (2) Relationship to student:
Household 2
Your answer
Guardian Primary Phone Number
Household 2
Your answer
Guardian Email
Household 2
Your answer
Guardian Mailing Address
Household 2- Number, Street, Town, State
Your answer
Has student ever been retained? *
If yes, what grade?
Your answer
Has student attended Lindale ISD before?
Please list school student previously attended: *
School Name, City and State
Your answer
Please check Special Programs Student has been enrolled in: *
Required
Sibling 1 Enrolled in Lindale ISD - Name
First & Last Name
Your answer
Sibling 1 Campus:
Sibling 2 Enrolled in Lindale ISD - Name
First & Last Name
Your answer
Sibling 2 Campus:
Sibling 3 Enrolled in Lindale ISD - Name
First & Last Name
Your answer
Sibling 3 Campus:
Sibling 4 Enrolled in Lindale ISD - Name
First & Last Name
Your answer
Sibling 4 Campus:
STUDENT HEALTH HISTORY
Does your student have Asthma? *
If YES, please list specifics, medications or reactions.
Your answer
Does your student have Diabetes? *
If YES, please list specifics, medications or reactions.
Your answer
Does your student have Food Allergies? *
If YES, please list specifics, medications or reactions.
Your answer
Does your student have Environmental Allergies? *
If YES, please list specifics, medications or reactions.
Your answer
Does your student have Seizures? *
If YES, please list specifics, medications or reactions.
Your answer
Has your student had any recent surgeries? *
If YES, please list surgeries.
Your answer
Does your student take daily medications? *
If YES, please list all medications.
Your answer
Does your student use an epi-pen? *
Please list any other health concerns
Your answer
Name of Primary Doctor and Contact Number *
Your answer
Enrolling Parent/Guardian Signature *
Your answer
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