Akronfairgrove
REGISTRATION/EMERGENCY FORM
Student Information
2017/2018 School Year
Student's Last Name
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Student's First Name
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Student's Middle Name
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Date of Birth
MM
/
DD
/
YYYY
Age
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Birthplace City
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Birthplace State
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Gender
Student Phone#
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Grade
Transfer From (If transferring in from another school)
School Name
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City
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State
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Ethnicity: Is this student Hispanic/Latino
SPECIAL HEALTH PROBLEMS: Allergies, Diabetes, and/or Epilepsy – Please Comment:
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WHERE IS THIS STUDENT LIVING NOW?
CHILD RESIDES WITH:
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