18 and under - The Learning Center of Ellis County
2019-20 School Year
Email address *
(Please obtain a gmail account if you don't already have one)!
Student Name: *
Your answer
Guardian's Home Phone: *
Your answer
Gender *
Student's Birth date: *
Your answer
Student's Street Address: *
Your answer
City, State, Zip: *
Your answer
Guardian(s): *
First and last names
Your answer
Alternative Phone number: *
Please provide another phone number where we may reach you during the day
Your answer
Student's number:
Student's cell phone number
Your answer
Does student have a high school diploma? *
What year did or will your student's class graduate from high school? *
Your answer
Is the parent/guardian's address the same as the student's? *
Please put main address for school mailings in the "other" box if it is different than the student's address.
Emergency Contact Name(other than guardian(s)) *
Your answer
Emergency Contact's number: *
Your answer
Emergency Contact 2 *
Your answer
Emergency Contact 2: *
Your answer
Is student Hispanic/Latino?
Race-
In what language does student read/write?
Your answer
City and State of last high school or learning center:
Your answer
Has student ever taken college courses, including CNA/CMA?
Migrant Education Program Information The Migrant Education Program (MEP) is authorized by Title I Part C of the Elementary and Secondary Education Act of 1965 (ESEA). The MEP provides formula grants to local education agencies to establish or improve education programs for children who may qualify for the Migrant Program. Please help us determine your child's eligibility for the Migrant Program by responding to the following question(s): * Has your family moved in the last 36 months to seek or obtain agriculture or fishing related work?
If we need to contact your further regarding your answers to these questions, please indicate the best phone number for us to contact you.:
Your answer
Your email: *
You may add student's email in same blank after yours if you like.
Your answer
Student's Primary Care Physician:
Your answer
Phone number for Physician
Your answer
Does student have any illness or learning difficulty which would interfere with learning? *
If so, please explain.
Illness name or learning difficulty...along with any special instructions related to health or testing (e.g. any testing accommodations outlined in I.E.P./504 Plan)
Your answer
Known Allergies? *
Your answer
I agree to notify The Learning Center of any changes to any of my contact information: (type initials) *
Your answer
The electronic signature below and its related fields are treated by Hays Unified School District 489 like a handwritten signature on a paper form. *
I affirm all the information provided is true and correct to the best of my knowledge. Please initial if you agree your information is true and correct. {Parent/Guardian initials}
Your answer
Type in your name (should be the name of the guardian who is enrolling the student and is responsible for student at all times). *
Your answer
Today's Date (Month Day Year) *
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YYYY
Office Use Only
Student PS #:
Your answer
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