Elmore City-Pernell Student Information 2020-2021 - Elementary School
Enrollment Form
Email address *
Student's Legal First Name *
Student's Legal Middle Name *
Student's Legal Last Name *
Today's Date: *
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Grade of student *
Last School Attended by Student *
Gender of Student *
Transfer Information: Do you and your child live in the Elmore City-Pernell School District? *
Residence Address: *
Mailing Address: *
Date of Birth: *
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Place of Birth City *
Select one or more of the following races. *
Required
Does your student have a Tribal Citizenship Card or documentation? Present a copy to the office for your child to qualify for the JOM Program. *
Please check the following programs in which your student has been a participant. *
Does your child have and IEP (Individualized Education Plan)? *
Primary (1st) Parent or Guardian's First & Last Name *
Primary (1st) Parent or Guardian's relationship to the child: *
Primary (1st) Parent's e-mail address
Primary (1st) Parent's Employer
Primary (1st) Parent's Phone Number - must be a working number (no dashes) *
Primary (1st) Parent's Business Phone Number (no dashes)
Primary (1st) Parent's Alternate Phone Number (no dashes)
Secondary (2nd) Parent's First & Last Name *
Secondary (2nd) Parent's relationship to the child: *
Secondary (2nd) Parent's e-mail address
Secondary (2nd) Parent's Employer
Secondary (2nd) Parent's Phone Number - must be a working number (no dashes) *
Secondary (2nd) Parent's Business Number (no dashes)
Secondary (2nd) Parent's Alternative Number (no dashes)
Emergency Contact #1 (not the parent or guardian) *
Emergency Contact #1 Relationship to student *
Emergency Contact #1 Phone Number (no dashes) *
Emergency Contact #2 (not the parent or guardian) *
Emergency Contact #2 Relationship to student *
Emergency Contact #2 Phone Number (no dashes) *
Emergency Contact #3 (not the parent or guardian)
Emergency Contact #3 Relationship to student
Emergency Contact #3 Phone Number (no dashes)
Emergency Contact #4 (not the parent or guardian)
Emergency Contact #4 Relationship to student
Emergency Contact #4 Phone Number (no dashes)
Please select which person you want to be contacted in case of bad weather or other school notices sent out via text messages. Only one selection is allowed. *
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