St. Joseph Registration Form
Student Information
Last Name *
Your answer
First Name *
Your answer
Middle Name *
Your answer
Home Phone No. *
Your answer
Date of Birth *
xx/xx/xxxx
Your answer
Physical Address - Street *
(E-911 preferred)
Your answer
Address - City *
Your answer
Address - Zip *
Your answer
Mailing Address
(if different)
Your answer
Mailing Address - City
Your answer
Maliing Address - Zip
Your answer
County *
Your answer
Gender *
Social Security No. *
Your answer
Ethnicity *
Living With *
Primary Custody *
District of Residence *
Your answer
Distance to School *
Your answer
Grade this Year *
Your answer
Bused to/from School? *
Doctor: *
Your answer
Doctor Phone: *
Your answer
Previous School Attended
(If not USD #389)
Your answer
City and State
of Previous school
Your answer
Custodial Information
Mother's Name *
Your answer
Daytime Phone *
Your answer
Home or Cell Phone: *
Your answer
Email Address: *
Your answer
Street:
if different than student
Your answer
City, State
if different than student
Your answer
Zip
if different than student
Your answer
Mother Employer *
Your answer
Father's Name *
Your answer
Daytime Phone:
Your answer
Home or Cell Phone:
Your answer
Email Address:
Your answer
Street
if different than student
Your answer
City, State
if different than student
Your answer
Zip
if different than student
Your answer
Father Employer
Your answer
Guardian(s) of Student
Name:
Your answer
Relationship
Your answer
Street:
Your answer
City, State
Your answer
Zip
Your answer
Daytime Phone:
Your answer
Emergency Contacts
First Contact Name *
Your answer
First Contact Relationship *
Your answer
First Contact Daytime Phone No: *
Your answer
Phone Type: *
Second Contact Name
Your answer
Second Contact Relationship
Your answer
Second Contact Daytime Phone No:
Your answer
Phone Type:
Third Contact Name
Your answer
Third Contact Relationship
Your answer
Third Contact Daytime Phone No:
Your answer
Phone Type:
Please list any special legal or medical information you wish us to be aware of concerning your student.
Your answer
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