Iberia Jr/Sr High School Student Information 20/21
Email address *
Student Full Legal Name: *
Date of Birth *
MM
/
DD
/
YYYY
SS#
Graduation Year
Race
Parent/Guardian with whom child resides with
Complete Mailing Address
Bus Stop (each student will have a designated pick up and drop off location
Father's Name & Work/Cell #
Mother's Name & Work/Cell #
Parent Email
Military Family Status
Clear selection
Emergency Contact Info (other than parent/guardian) Name & Phone #
Emergency Contact Info (other than parent/guardian) Name & Phone #
Emergency Contact Info (other than parent/guardian) Name & Phone #
Family Doctor & Phone #
Family Dentist & Phone #
Hospital Preference
Special circumstances we should be aware of (allergies, asthma, diabetes, etc.)
Signature of Parent/Guardian & Date
School personnel are not allowed to dispense medication to students who are ill without the permission from their parents or legal guardian. Please take the time to complete this portion if you want your child to receive non-aspirin pain reliever at school. We will also administer other medications sent from home with specific directions for administration time and what the medication is being used for. If your child takes a prescription medication daily and it is to be administered by the nurse, it will need to be in a prescription bottle clearly marked with the child's name, name of medication, dosage, and how it its supposed to be administered. I request that my child be given non-aspirin pain relievers (Tylenol) or generic substitutes during the school year in accordance with the board policy. I authorize the school nurse or designee to give my child medication. I will not hold the school staff responsible for any undesired reaction that may occur from the medication. School Nurse 573-793-2896. Student's Name & Parent/Guardian signature
I give permission for my child's name, address, and phone number to be released to all military, college, commercial requests and name/photograph to be placed on the Iberia School web page and local newspapers. Signature of Parent/Guardian & Date
I hereby affirm that my student has/has not been expelled or suspended from any previous school.
Clear selection
I hereby affirm that this child is a resident of the Iberia School District under penalty of the Safe Schools Act. Signature of Parent Guardian:
Race/Ethnicity/Language Form: Student Name:
Are you Hispanic/Latino?
Clear selection
Please select one or more races from the following five racial groups:
Do you use a language other than English?
Clear selection
Is a language other than English used in your home?
Clear selection
Are you sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason?
Clear selection
Are you currently residing at a motel, hotel, in a car, or at a campsite because your home has been damaged or because of economic reasons?
Clear selection
Are you currently residing in a shelter?
Clear selection
Are you currently living in a temporary housing arrangement due to economic hardship?
Clear selection
Has either the parent, the guardian, or the child been employed (or is currently employed) within the past three years as a migratory worker in some form of temporary employment or seasonal agricultural or agricultural-related work?
Clear selection
What is the primary language spoken in the home?
List any language other than English, used at the home.
Was English the first language the student learned?
Clear selection
Can the student speak a language other than English?
Clear selection
Parent/Guardian Signature & Date
Submit
Never submit passwords through Google Forms.
This form was created inside of Iberia R-V School. Report Abuse