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 *
Name Used
Race *
Birthdate *
MM
/
DD
/
YYYY
S.S. # *
Grade this year
Is the student in foster care?
Clear selection
Previous School attended
Student's Mailing address
Student's Home Phone # 573
Father's Full Name
Father's Address
Dad's Work #
Dad's Home #
Dad's Call #
Mother's Full Name
Mother's Address
Mom's Work #
Mom's Home #
Mom's Cell #
Step Parent(s)/Guardian(s) Name(s)
Guardian's Address
Guardian's Home #
Guardian's Work #
Guardian's Cell #
Parent(s)/Guardian(s) with whom child resides with
Authorization to pick child up from school and emergency contact other then parent. Emergency Contact #1/Phone #:
Authorization to pick child up from school and emergency contact other then parent. Emergency Contact #2/Phone #:
Authorization to pick child up from school and emergency contact other then parent. Emergency Contact #3/Phone #:
Authorization to pick child up from school and emergency contact other then parent. Emergency Contact #4/Phone #:
Directions for Bus Driver : Directions to Home
Directions for Bus Driver : Directions to Other Bus Stop
Other Household Members/Relationship/Age
Special circumstances (Allergies, Asthma, Diabetes, Custody, etc.)
Family Doctor/Phone Number
Family Dentist/Phone Number
Hospital Preference
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
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
Military Family Status
Clear selection
Race/Ethnicity/Language
Is the first language of the student English?
Clear selection
Is a language other than English used in the home?
Clear selection
Are you Hispanic/Latino?
Clear selection
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?
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
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?
Clear selection
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