Big Stone City School District #25-1 Registration Form
**Complete a registration form for EACH student enrolling**

**All fields are required so if you do not have an answer to a specific question please enter "NONE" or "NA"**

**Please select [FILL OUT FORM] to start**

Student Information
Student First Name
Your answer
Middle Initial
Your answer
Student Last Name
Your answer
City
Your answer
Address
Your answer
State
Your answer
Zip Code
Your answer
Birthdate
MM
/
DD
/
YYYY
Gender
Select from the drop down list
Grade
Select from the drop down list
Race/Ethnicity
Select from the drop down list
Resident School District
Select from the drop down list
Parent/Guardian Information
Parent Last Name
Your answer
Parent First Name
Your answer
Parent Home Phone #
(xxx-xxx-xxxx format)
Your answer
Parent Cell Phone #
(xxx-xxx-xxxx format)
Your answer
Parent Work Phone #
(xxx-xxx-xxxx format)
Your answer
Parent Email Address
Your answer
Parent Place of Work
Your answer
Other Parent/Guardian Information
Other Parent Last Name
Your answer
Other Parent First Name
Your answer
Other Parent Home Phone #
(xxx-xxx-xxxx format)
Your answer
Other Parent Cell Phone #
(xxx-xxx-xxxx format)
Your answer
Other Parent Work Phone #
(xxx-xxx-xxxx format)
Your answer
Other Parent Email Address
Your answer
Other Parent Place of Work
Your answer
Other Sibling Information
Data required for future projections on student count
Name of Siblings and Ages
List all siblings along with their ages
Your answer
Yellow Ribbon Program
This information below is gathered to support and assist student veterans
Does your student have a family member in the military?
If yes, please list family members below and the relationship to the student
Your answer
Emergency Contact Information
Name
Your answer
Relationship to Student
Your answer
Home Phone #
(xxx-xxx-xxxx format)
Your answer
Cell Phone #
(xxx-xxx-xxxx format)
Your answer
Work Phone #
(xxx-xxx-xxxx format)
Your answer
Doctor Name
Your answer
Doctor Clinic Name
Your answer
Doctor Clinic Phone #
Your answer
Dentist Name
Your answer
Dentist Clinic Name
Your answer
Dentist Clinic Phone #
Your answer
In the event that a parent/guardian or emergency contact cannot be reached, can emergency care be authorized for your child?
Storm Home
MUST be completed if you child resides outside of the Big Stone City limits
Name
Your answer
Address
(full address; street, city, state, zip code)
Your answer
Home Phone #
Your answer
Cell Phone #
Your answer
In the event of a storm, my child will be:
(examples: picked up by______, ride the bus, walk, etc)
Your answer
Title III Home Language Survey
A local school district is required to administer a home language survey to ALL students enrolling in the district as the first step in the screening process to identify students with limited English proficiency. Many districts include this survey on their initial enrollment card or document. The home language survey consists of the following four questions:
What is the language most frequently spoken at home?
Your answer
What language did your child learn when he/she first began to talk?
Your answer
What language does your child most frequently speak at home?
Your answer
What language do you most frequently speak to your child?
Your answer
Permission to Administer Acetaminophen (Tylenol) & Cough Drops
The South Dakota Department of Health requires parental permission for all the students receiving any type of medication in school. With permission, the office will administer Acetaminophen (Tylenol) with dosages given according to weight and age of the student.
Acetaminophen (Tylenol)
Select from the drop down list
Cough Drops
Select from the drop down list
Medication Request/Release
Law requires the school district to have on file, a signed permission form indicating that it is acceptable for school staff to administer any prescription medication during school hours. When brought to school, the medication label must include the name of the pharmacy, patient, prescribing physician, and direction for use. It must be kept at the school office. If in the future your child requires the use of prescription medication, you may contact the school for a new form to fill out and sign.
Medication
Select from the drop down list
Prescription Medication Release
Physician Name
Your answer
Pharmacy Name
Your answer
Medication Name
Your answer
Dosage of Medication
Your answer
Time(s) to Administer Medication
Your answer
Reason for taking medication
Your answer
Parent/Guardian Electronic Signature for Prescription Medication Release
Electronic Signature Required (by typing your name below you approve and to the best of your knowledge, all information is correct
Your answer
Date Electronically Signed
MM
/
DD
/
YYYY
Field Trip Permission and Authorization
Educational field trips may be taken during the school year. Parent notification will be made in advance of the field trip by school teacher staff or office staff
Field Trips
Select from the drop down list
Media Permission and Authorization
Media
(all media outlets will include but not limit to, newsletters, webpages, newspapers, Facebook, etc)
Internet Permission and Authorization
By the Student and Parent Electronic Signatures below, all parties are under the following understanding that:

Student - it is understood what is acceptable use of the internet and agree to use it properly. I further understand that any improper use may constitute a violation of law. Should I commit any violation, my access privileges may be revoked, school disciplinary action may be taken, and/or appropriate legal action may be taken.

Parent/Guardian - it is understood what is acceptable use of the internet and access is designed for educational purposes. The school district has taken precautions to eliminate controversial material through its monitoring process. I also recognize it is impossible for the district to restrict access to all controversial materials, and will not hold the school district responsible for materials acquired on the internet.

Student Electronic Signature
Your answer
Parent/Guardian Electronic Signature
Also by signing your electronic signature you are giving permission for your child to access the internet
Your answer
Date Electronically Signed
MM
/
DD
/
YYYY
Food Allergies
Please list all food related allergies your child has.

For special diet considerations, you MUST have a doctor's signature on a Special Diet Prescription Form submitted to the school each school year. Please ask for this in the Business Office.

Food Allergies
Your answer
Other Allergies
Please list other potentially dangerous allergies.

Please provide a doctor's note and instructions with any inhalers or epinephrine products.

Other Allergies
Your answer
School Handbook
Please sign to indicate that you have been offered a copy of the Student/Parent Handbook. Student/Parent Handbooks are available to view on the Big Stone City School website. They are also available via email or as a hard copy upon request.
Student Electronic Signature
Your answer
Parent/Guardian Electronic Signature
Your answer
Date Electronically Signed
MM
/
DD
/
YYYY
Academic Probation Policy
Grades 4-8

All students in grades 4-8 and their parents must sign this annually prior to participating in practice or games. By signing this we acknowledge that you have received and read the information provided.

Students with any of the following grades on a report card or mid-term report will be regarded as being ineligible: F or Incomplete

This ineligibility extends to extracurricular sports and activities (Big Stone City and Ortonville Junior High). This includes running the clock and student council activities. The student with an F or U will remain on the ineligibility list until the incomplete is completed or failure becomes passing. A student with an incomplete may participate as soon as the work is finished unless the grade is an F or U. Once the student is found to be in compliance with grades, they may compete immediately.

Student Electronic Signature
Your answer
Student Grade Level
Parent/Guardian Electronic Signature
Your answer
Date Electronically Signed
MM
/
DD
/
YYYY
Athletic Participation Permission
Grades 4-8

This permit is required by the Big Stone City Public School District 25-1 to be filed with the school office before any student may take part in any school athletic activities.

You are not required to participate if you complete this form and decide not to be involved at a later date.

I give permission for him/her to go with the coach or other representative of the school on any authorized trips.

I agree to be responsible for the safe return of all athletic equipment and/or uniforms issued by the school.

I consent to the release of student directory information as it applies to school-related activities such as athletics.

I give permission to participate in organized athletics, realizing that such activity involve the potential for injury which is inherent in all sports. I/we acknowledge that even with the best coaching and strict observance of the rules, injuries are still a possibility. On rare occasions, these injuries can be so severe as to result in disability, paralysis, quadriplegia, or even death.

I acknowledge that I have read and understand this warning.

PLEASE NOTE, students in grades 7-8 must have an athletic physical form on file with the school. It is good for three years.

Sports
Please choose from the sports listing
Student Electronic Signature
Your answer
Parent/Guardian Electronic Signature
Your answer
Date Electronically Signed
MM
/
DD
/
YYYY
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