Elmore City-Pernell Student Information 2019-2020
Enrollment Form
Legal Student Name:
Your answer
Date: *
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Grade of student *
Last School Attended by Student *
Your answer
Gender of Student *
Residence Address: *
Your answer
Mailing Address: *
Your answer
Date of Birth: *
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YYYY
Place of Birth City *
Your answer
Race: *
Does your student have a Tribal Citizen 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. *
Required
Mother's Name: *
Your answer
Mother's e-mail address
Your answer
Mother's Employer
Your answer
Mother's Phone Number - must be a working number (no dashes) *
Your answer
Mother's Business Phone Number (no dashes)
Your answer
Mother's Alternate Phone Number (no dashes)
Your answer
Father's Name *
Your answer
Father's e-mail address
Your answer
Father's Employer
Your answer
Father's Phone Number - must be a working number (no dashes) *
Your answer
Father's Business Number (no dashes)
Your answer
Father's Alternative Number (no dashes)
Your answer
Emergency Contact #1 (not the parent or guardian) & Relationship to student *
Your answer
Emergency Contact #1 Phone Number (no dashes) *
Your answer
Emergency Contact #2 (not the parent or guardian) & Relationship to student *
Your answer
Emergency Contact #2 Phone Number (no dashes) *
Your answer
Emergency Contact #3 (not the parent or guardian)& Relationship to student *
Your answer
Emergency Contact #3 Phone Number (no dashes) *
Your answer
Emergency Contact #4 (not the parent or guardian) & Relationship to student *
Your answer
Emergency Contact #4 Phone Number (no dashes) *
Your answer
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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