Iberia R-V Elementary Enrollment Form
It is a requirement that we have the following information on file at Iberia R-V School.
Student's Full Legal Name *
Your answer
Name Used
Your answer
Race *
Birthdate *
MM
/
DD
/
YYYY
S.S. # *
Your answer
Grade this year
Your answer
Is the student in foster care?
Previous School attended
Your answer
Student's Mailing address
Your answer
Student's Home Phone # 573
Your answer
Father's Full Name
Your answer
Father's Address
Your answer
Dad's Work #
Your answer
Dad's Home #
Your answer
Dad's Call #
Your answer
Mother's Full Name
Your answer
Mother's Address
Your answer
Mom's Work #
Your answer
Mom's Home #
Your answer
Mom's Cell #
Your answer
Step Parent(s)/Guardian(s) Name(s)
Your answer
Guardian's Address
Your answer
Guardian's Home #
Your answer
Guardian's Work #
Your answer
Guardian's Cell #
Your answer
Parent(s)/Guardian(s) with whom child resides with
Your answer
Authorization to pick child up from school and emergency contact other then parent. Emergency Contact #1/Phone #:
Your answer
Authorization to pick child up from school and emergency contact other then parent. Emergency Contact #2/Phone #:
Your answer
Authorization to pick child up from school and emergency contact other then parent. Emergency Contact #3/Phone #:
Your answer
Authorization to pick child up from school and emergency contact other then parent. Emergency Contact #4/Phone #:
Your answer
Directions for Bus Driver : Directions to Home
Your answer
Directions for Bus Driver : Directions to Other Bus Stop
Your answer
Other Household Members/Relationship/Age
Your answer
Special circumstances (Allergies, Asthma, Diabetes, Custody, etc.)
Your answer
Family Doctor/Phone Number
Your answer
Family Dentist/Phone Number
Your answer
Hospital Preference
Your answer
I request that you give Non-Aspirin pain reviler (Tylenol) or generic substitutes to my child during the school year in accordance with board policy. See medications in handbook. 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. Please type your name below to agree.
I hereby affirm that my enrolling child Has or Has Not been expelled or suspended from any previous school
I hereby affirm that enrolling child is a resident of Iberia R-V School District under penalty of the Safe Schools Act. Please type your name below to agree
Your answer
I give permission to publicize my child's picture, work or name on the district web page, facebook, and or newspaper. Please type your name below to agree
Your answer
Military Family Status
Race/Ethnicity/Language
Is the first language of the student English?
Is a language other than English used in the home?
Are you Hispanic/Latino?
Please select one or more races from the following five racial groups:
Homeless Enrollment: Are you sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason?
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?
Are you currently residing in a shelter?
Are you currently living in a temporary housing arrangement due to economic hardship?
Migrant: Has either the parent, the guardian, or the child been employed (or is currently employed) within the past three years as a migratory working in some form of temporary employment or seasonal agricultural or agricultural-related work?
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