Borland Elementary 3-5 Registration Form

3-5 Registration Form

Fill out the form carefully for registration. You will also need to provide the following required pieces of documentation:- Original birth certificate with the raised seal- Up-to-Date Immunization Record (Available at the Health Department)- Picture Identification- Two proofs of residency with your name and current address: Picture Identification (Picture identification is required and can also be considered as one proof ONLY if the current address is displayed on the ID.)Utility bill, bank statement, or check stub (Must be dated within 2 months) Lease or purchase agreement or car registration (Must be currently active)
Student Name*

First NameMiddle NameLast Name
Gender*
Grade*
Date of Birth*

MonthDayYear
Birthplace*
Special Education*
Speech*
*If yes to either special education or speech question, stop here and contact the CEC at 810-724-9853. Please attach most current IEP.
Attach current IEP

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Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
County of Residence*
Home Phone*

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Please list any health considerations, allergies, or medications:*
Ethnicity: is this student (or are you) Hispanic/Latino?*

No, not Hispanic/LatinoYes, Hispanic/Latino
Race*
Is this student tribally affiliated?*

Yes, the student is tribally affiliatedNo, the student is not tribally affiliated
If the student is tribally affiliated, what is their primary tribal affiliation? (Choose only one)
Parent and/or Guardian Information
Father/Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status*
Employer Name/Occupation*
Work Phone*

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Active Military*

YesNo
Email address*
example@example.com
Mother/Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status*
Employer Name/Occupation*
Work Phone*

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Active Military*

YesNo
Email address*
example@example.com
Non-Custodial Parent Information

Court documentation must be provided and included in your child's school record if non-custodial parent cannot pick up student from school.
Non-Custodial Parent Name:

First NameLast Name
Who has legal Custody?
Cell Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Is student allowed to leave with non-custodial parent?

YesNo
Emergency Contacts (other than parents/guardians)
Family Information
Brothers
Sisters
Other Student Information
Last School Attended:*
Date Left:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Comments and/or additional information:
Presently, is your family living in any of the following situations? Check one box:*

Staying in a shelter, temporary trailer, or waiting for foster care placementDoubled up-sharing the housing with others/relatives due to loss of housing, economic hardship or similar reasonLiving in a motel or hotel due to loss of housing, economic hardship or similar reasonLiving in a motel or hotel due to loss of housing, economic hardship or similar reasonMoving from place to placeLiving with an adult that is not a parent or legal guardianNone of the above
Two Proofs of Residency with name and current address:

Picture Identification (Picture identification is required and can also be considered as one proof ONLY if the current address is displayed on the ID.)Utility bill, bank statement, or check stub (Must be dated within 2 months) Lease or purchase agreement or car registration (Must be currently active)
First Form of Proof of Residency

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Second Form of Proof of Residency

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I understand that there may be online courses offered to my child and I give my consent for my student to take any course assigned.
Please sign and date the Registration Form below:
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

3-5 Registration Form

*If yes to either special education or speech question, stop here and contact the CEC at 810-724-9853. Please attach most current IEP.

Parent and/or Guardian Information

Non-Custodial Parent Information

Emergency Contacts (other than parents/guardians)

Family Information

Other Student Information

Two Proofs of Residency with name and current address:

Please sign and date the Registration Form below: