Central High School New Student Registration Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Email *

Students First Name: *

Middle Name:

Last Name: *

Birthdate: *

YYYY

Gender:

Male

Female

Clear selection

Next Year Grade: *

7th

8th

9th

10th

11th

12th

Previous School Attended *

SSN (Optional):

Hispanic/Latino Ethnicity:

Yes

Clear selection

Primary Race (Please select only ONE).

American Indian or Alaska Native: (A person having orgins in any of the original peoples of North and South America, Including Central America, and who maintains tribal affiliation or community attachment)

Asian: (A person having orgins in any of the origical peoples of Far East, Souteas Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Phillippine Islands, Thailand and Vietnam)

Black or African American: (A person having origins in any of the black racial groups of Africa)

Native Hawaiian or Other Pacific Islander: (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands)

White: (A person having origins in any of the original people of Europe, Middle East or North Africa)

Language Spoken at Home: *

Parent/Guardian 1:

Name:

Parent/Guardian 1:

Relationship to Student:

Parent/Guardian 1:

Language of Correspondence

Parent/Guardian 1:

Mailing Address:

Physical Address:

Parent/Guardian 1:

City:

Parent/Guardian 1:

State:

Parent/Guardian 1:

Zip Code:

Parent/Guardian 1:

Email:

Parent/Guardian 1:

Cell Phone:

Parent/Guardian 1:

*Alert Phone:

*Alert Phone is used by the district's automated phone message system.

Parent/Guardian 1:

Student Primarily Resides with this Guardian.

Yes

Clear selection

Parent/Guardian 2:

Name:

Parent/Guardian 2:

Relationship to Student:

Parent/Guardian 2:

Language of Correspondence:

Parent/Guardian 2:

Mailing Address:

Parent/Guardian 2:

City

Parent/Guardian 2:

State:

Parent/Guardian 2:

Zip Code:

Parent/Guardian 2:

Email:

Parent/Guardian 2:

Cell Phone:

Parent/Guardian 2:

*Alert Phone:

*Alert Phone is used by the district's automated phone message system.

Parent/Guardian 2:

Student Primarily Resides with this Guardian.

Yes

Clear selection

Student: City of Birth

Student: State of Birth

Student: Birth Country:

Travel Information: Travel To School (Please check one) *

Bus

Drives Self

Parent/Guardian (includes walkers, child care vans, etc.)

District Paid Transportation

Emergency Contact Information (Contacts other than Guardians to be called in case of an emergency)

Does this child have internet access at home? *

Yes

If there is no Internet Access, what is the reason this child does Not have internet Access? *

Not Available

Not Affordable

Not Applicable

Other

Is the Internet Performance Acceptable for learning activities? *

Yes- experience very few or no interruptions in learning activities caused by poor internet performance in the primary place of residence.

Sometimes- regularly experiences interruptions in learning activities internet caused by poor internet performances in their primary place of residence.

No- unable to complete learning activities due to poor internet performance in their primary place of residence.

Other:

What kind of devices does this child use most often to complete learning activities away from school? *

Desktop Computer

Laptop Computer

Tablet

Chromebook

Smartphone

None

Other

What is the source of this primary learning device? *

District Provided

Personal

Other

What is the child's access to this primary learning device? *

Shared

Not Shared

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Helena-West Helena School District.

Does this form look suspicious? Report

Forms