Elementary Registration Form PreK EC K EC

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M or F Male (Please circle gender)

(Please circle grade)

_______________

___________________

(Enrollment Date)

(For office use only)

STUDENT INFORMATION Student’s Last Name:

_______________________________ First (Legal) Name: _________________________

Middle (Legal) Name: _______________________________ Preferred Name: Student’s Address:

_______________________________ ___________________________ ______________ (Street)

Date of Birth:

_________________________

(City)

(Zip Code)

__________________ Place of Birth: ___________________________ ______________ (City)

Home Phone:

(____)_____________

(State)

Race: ___________________________ Black or African American (White, Black, Hispanic, American Indian, Other)

FAMILY INFORMATION Name of person(s) student lives with: ______________________________________________________________

Foster Parent Relationship to Student: (Circle) Both Parents

Mother

Father

Grandparent(s)

Foster Parent

Stepparent(s)

Other

Mother’s Name: _______________________ Employer: _________________ Work Phone: (___)____________ Father’s Name:

_______________________ Employer: _________________ Work Phone: (___)____________

Mother’s Cell:

________________________________

Father’s Cell:

_________________________________

Parent’s Email Address: ___________________________________________________________________________ Names of siblings who attend Hoopeston Area Schools: Name: _________________________

Grade: ____

Name: _________________________

Grade: ____

Name: _________________________

Grade: ____

Name: _________________________

Grade: ____

Is any immediate family an active member of the U.S. Military? No YES or NO

Who? _____________________

EMERGENCY INFORMATION In case of an emergency, whom should we call? Parents – Please list yourself if you’re to be called first. 1st Contact: _____________________ Phone (___)____________ Relationship (to student): __________________ 2nd Contact: _____________________ Phone (___)____________ Relationship (to student): __________________ 3rd Contact: _____________________ Phone (___)____________ Relationship (to student): __________________

TRANSPORTATION INFORMATION Will your student walk home from school?

No YES

or

NO

Will your student be picked up at school?

YES No

or

NO

Will your student ride a bus after school?

YES No

or

NO

/

Most regularly by whom? ___________________

Which bus will your student ride AFTER school? Please do not check the school your student attends. _____ Early Childhood

_____ Maple

_____ Honeywell

_____ John Greer

_____ H.S./Country

Health Information Form In an effort to keep school staff informed so they can best meet your child’s needs, Please check any health issues that your child has. ____ ADD/ADHD

____ Allergies (seasonal or otherwise)

____ Anxiety

____ Asthma

____ Bipolar Disorder

____ Bleeding problems

____ Bone/Joint problems

____ Bowel/bladder problems

____ Cardiac/Heart problems

____ Diabetes

____ Frequent colds/respiratory infections

____ Frequent headaches /migraine headaches

____ Frequent stomachaches

____ Hearing problems

____ Seizures

____ Sleeping problems

____ Speech problems

____ Vision problems

____Other: ________________________________________________________________________________________________ Please list any specific allergies: ____________________________________________________________________________ ___________________________________________________________________________________________________________ Please list any medications your child will need to take at school: ____________________________________________ ___________________________________________________________________________________________________________ Please list any medications your child routinely takes outside of school: _______________________________________ ___________________________________________________________________________________________________________

If your child has any serious medical conditions, please speak directly with the building principal and/or your child’s teacher regarding your concerns. -------------------------------------------SPANISH VERSION------------------------------------------En un esfuerzo por mantener al personal escolar informado por lo que mejor puede satisfacer las necesidades de su hijo, por favor marque cualquier problema de salud que tiene su hijo. ____ ADD/ADHD

____ Alergias estacionales (o no)

____ Ansiedad

____ Asma

____ Trastorno bipolar

____ Problemas de hemorragia

____ Problemas de huesos/ coyonturas

____ Problemas con la vejiga Y intestino

____ Problemas cardiacos

____ Diabetes

____ Frequentes infecciones respiratorias

____ Frecuentes dolores de Cabeza/migrañas

____ Frequentes dolores de

____ Problemas de audición

____ Ataques estómago

____ Problemas de sueno

____ Problemas de habla

____ Proglemas de la visión

____ Otro: _______________________________________________________________________________________________ Por favor anote cualquier alergia especifica: _______________________________________________________________ Por favor, indique todos los medicamentos que su hijo tendrá que tomar en la escuela: ______________________ ___________________________________________________________________________________________________________ Por favor, indique todos los medicamentos que su hijo toma habitualmente fuera de la escuela: _____________ ___________________________________________________________________________________________________________

Si su hijo tiene alguna condición medica seria, hable directamente con el director de la escuela y/o el maestro de su hijo acerca de sus preocupaciones.