Glen Rose Kindergarten Registration
2022-2023 School year
Student Name
*
Last Name
Middle Name
First Name
Suffix
Grade
*
Gender
*
Social Security #
*
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is this student a twin (or triplet, quadruplet, etc.)?
*
Yes
No
Hispanic or Latino Ethnicity?
*
Yes
No
Primary Race (check all that apply)
*
White
Asian
Black
Hispanic
Native American
Hawaiian/Pacific Islander
Previous School Attended
City and State of School
Legal Guardian of Child
*
Both Parents
Mother Only
Father Only
Primary Phone Number for ALERT NOW (District's automated phone message system)
*
-
Area Code
Phone Number
Mother/Guardian
First Name
Last Name
Mother/Guardian Workplace
Phone Number
-
Area Code
Phone Number
Work Number
-
Area Code
Phone Number
Father/Guardian
First Name
Last Name
Father/Guardian Workplace
Phone Number
-
Area Code
Phone Number
Work Number
-
Area Code
Phone Number
Step Parent's Name (if living in household)
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Is guardian currently serving in the active or reserve military?
*
Yes
No
Is any member employed as a migrant worker?
*
Yes
No
How Many persons are in household?
*
Please list siblings that attend Glen Rose and list grade level
Medical Information
Does your child have any physical/mental impairments that substantially limits a major life activity?
*
Yes
No
If Yes, please list the impairment (this will initiate the process to identify students who should be covered under section 504)
In case of emergency, please list three names of people to be contacted other than parent/guardian
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
List any medical problems and/or allergies
List any medications presently taking
Language Information
What language is spoken in your home most of the time?
*
What language does the student speak most of the time?
*
What language do parents speak to the students most of the time?
*
Housing Information
Are you sharing housing of other persons due to loss of housing, economic hardship, or similar reason
*
Yes
No
Housing Arrangements
*
Apartment
House
Car
Camper
Bus
Family Shelter
Youth Shelter
Park/Campsite
How long have you lived at the above location?
*
Living with
*
father and step-mother
mother and step-father
both parents
father only
mother only
foster parents
legal guardian
grandparents
homeless
Transportation Information
How will your student be transported to and from school?
*
car
bus
Directions to home (from school)
*
How many miles from school
*
What county do you live in?
*
Home Internet Information
Internet Type
*
Cellular Network
Community Provided Wi-Fi
Dial-up
Hot Spot
None
Other
Device Access Source
*
District Provided
Other
Personal
Learning Device
*
Chromebook
Desktop Computer
Laptop Computer
None
Other
Smartphone
Tablet
Internet Access Barrier
*
Not Affordable
Not Available
Other
N/A
Internet Performance
*
No (unable to access internet)
Sometimes (regularly experience internet interruptions)
Yes (few or no internet interruptions)
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