Des Arc Public Schools Registration
Student Enrollment
Email address *
GENERAL INFORMATION
Which school will your child be attending? *
Student First Name: *
Student Middle Name: *
Student Last Name: *
Grade: *
Student Date of Birth: *
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Student Gender: *
Student Social Security Number: *
Student Primary Race: *
If the family does not have a fixed, regular and adequate nighttime residence, choose one of the following: *
Primary Language Spoken at Home: *
Required
Student Physical 911 Address: *
Student Physical 911 Address (City): *
Student Physical 911 Address (State): *
Student Physical 911 Address (Zip Code): *
Student Physical 911 Address (County): *
Student Mailing Address: *
Student Mailing Address (City): *
Student Mailing Address (State): *
Student Mailing Address (Zip Code): *
Student Mailing Address (County): *
Does the student currently have access to internet services at home? *
Required
How reliable is internet services at home? *
Do not have services.
Excellent
Student Primarily Lives With: *
PARENT/GUARDIAN CONTACT INFORMATION
Parent/Guardian 1 - Name: *
Parent/Guardian 1 - Relationship to Student: *
Parent/Guardian 1 - Address: *
Parent/Guardian 1 - Phone Number (This is the number that will be used for School Messenger Calls.): *
Parent/Guardian 1 - Email: *
Parent/Guardian 1 - Employer: *
Parent/Guardian 1 - Work Number: *
Parent/Guardian 1 - Student primarily resides with this guardian. *
Parent/Guardian 2 - Name: *
Parent/Guardian 2 - Relationship to Student: *
Parent/Guardian 2 - Address: *
Parent/Guardian 2 - Email: *
Parent/Guardian 2 - Phone Number (This is the number that will be used for School Messenger Calls.): *
Parent/Guardian 2 - Employer: *
Parent/Guardian 2 - Work Number: *
Parent/Guardian 2 - Student primarily resides with this guardian. *
TRAVEL INFORMATION
Travel to School: *
Travel to Home: *
How will your child be getting home the 1st Day? *
EMERGENCY CONTACT INFORMATION
Emergency Contact 1 - Name (First & Last): *
Emergency Contact 1 - Relationship to student: *
Emergency Contact 1 - Phone Number: *
Emergency Contact 2 - Name (First & Last): *
Emergency Contact 2 - Phone Number: *
Emergency Contact 2 - Relationship to student: *
Emergency Contact 3 - Name (First & Last): *
Emergency Contact 3 - Relationship to student: *
Emergency Contact 3 - Phone Number: *
ADDITIONAL STUDENT INFORMATION
City of Birth: *
State of Birth: *
Is this student living in a motel, car, campsite, or with more than one family? *
Is this child a dependent of an active reserve member of a branch of the United States Armed Services? *
Is this student a twin (or a triple, quadruplet, etc.)? *
Are there any legal restrictions regarding this student such as divorce decrees, court orders, CPS placement, etc? ***** If yes, the most current legal documentation MUST be provided to the school. *
STUDENT ACADEMIC INFORMATION
Preschool Participation: *
Preschool program student attended and location, if any:
Please check if student is currently or has previously received any of the following services (SELECT ALL THAT APPLY): *
Required
TRANSFERRING STUDENTS
Has your student ever attended Des Arc Public Schools? *
If student has attended Des Arc Des Arc Public Schools, what year(s)?
Has student ever repeated a grade? *
What grade(s), if any did student repeat?
PREVIOUS SCHOOL HISTORY
Last school attended (NAME OF SCHOOL, CITY & STATE):
Grade(s) attended:
Other Schools attended & grade(s):
SIBLINGS THAT ATTEND DES ARC PUBLIC SCHOOLS
Sibling 1 that also attends Des Arc School District (FIRST & LAST NAME):
Sibling 1 that also attends Des Arc School District (GRADE):
Sibling 2 that also attends Des Arc School District (FIRST & LAST NAME):
Sibling 2 that also attends Des Arc School District (GRADE):
Sibling 3 that also attends Des Arc School District (FIRST & LAST NAME):
Sibling 3 that also attends Des Arc School District (GRADE):
Sibling 4 that also attends Des Arc School District (FIRST & LAST NAME):
Sibling 4 that also attends Des Arc School District (GRADE):
Sibling 5 that also attends Des Arc School District (FIRST & LAST NAME):
Sibling 5 that also attends Des Arc School District (GRADE):
Please choose which of the following situations the student currently lives in (you can choose more than one): *
Required
If you are living in shared housing, please check all of the following reasons that apply: *
Required
Is student living apart from parents or guardian? *
Number in Family (The number of Immediate members living in house (Parent, Guardian, Siblings): *
Number in Household (the total number of people living in the house): *
List the name and relationship to the child enrolled of all family members in the household: *
Please check the services needed or desired: *
Required
STATEMENT OF STUDENT HANDBOOK 2020-2021 Des Arc School Board and Administration request that students and parents become familiar with Des Arc Elementary/Des Arc High School Policies. These policies have been adopted 5/22/2017 by the local Board of Education and approved by the state Department of Education. To ensure every student has received a copy of this student handbook, state law requires documentation of student and parent receipt of school policies. This document is included in student files. By my digital signature, I acknowledge that I have received and read the student handbook that governs the policies of Des Arc Elementary. I have completed the Corporal Punishment & Photo sections. WOULD YOU LIKE TO RECEIVE A COPY OF STUDENT HANDBOOK? *
Required
Corporal Punishment: *
Required
Permission to display photo of students: *
Permission to display photo of students (any public site): *
MEDICATION ADMINISTRATION CONSENT & HEALTH QUESTIONAIRE
Please check the all non-prescription medications that school personnel may administer: *
Required
Reason for Medication 1:
Name of physician or dentist for Medication 1:
Dosage of Medication 1:
Instructions for administering Medication 1:
Other Instructions Medication 1:
Is Medication 1 given at school?
Clear selection
Name of Medication 2:
Reason for Medication 2:
Name of physician or dentist for Medication 2:
Dosage of Medication 2:
Instructions for administering Medication 2:
Other Instructions Medication 2:
Is Medication 2 given at school?
Clear selection
Name of Medication 3:
Reason for Medication 3:
Name of physician or dentist for Medication 3:
Dosage of Medication 3:
Instructions for administering Medication 3:
Other Instructions Medication 3:
Is Medication 3 given at school?
Clear selection
Name of Medication 4:
Reason for Medication 4:
Name of physician or dentist for Medication 4:
Dosage of Medication 4:
Instructions for administering Medication 4:
Other Instructions Medication 4:
Is Medication 4 given at school?
Clear selection
Name of Medication 5:
Reason for Medication 5:
Name of physician or dentist for Medication 5:
Dosage of Medication 5:
Instructions for administering Medication 5:
Other Instructions Medication 5:
Is Medication 5 given at school?
Clear selection
Name of Medication 6:
Reason for Medication 6:
Name of physician or dentist for Medication 6:
Dosage of Medication 6:
Instructions for administering Medication 6:
Other Instructions Medication 6:
Is Medication 6 given at school?
Clear selection
Please type primary physician name: *
Please type primary physician address: *
Please type primary physician phone number: *
Please list date of last complete medical exam: *
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Please type primary dentist name: *
Please type primary dentist address: *
Please type primary dentist phone number: *
Please list date of last complete Orthodontics exam: *
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Please select if your child has any of the following health issues (Allergies require Action Plan & Asthma requires Action Plan & inhaler at school at all times.) *
Required
Please provide additional information, if you selected any of the health issues.
Parent/Guardian Signature (Please type your first & last name.) *
Submit
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