Student Enrollment Form 20-21

Student Enrollment

Wewoka Public Schools
Name*

First NameMiddle NameLast Name
Social Security Number*
xxx-xx-xxxx
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Date
Birth Place (City, State)
Birth Certificate

Cancelof
Grade *
Educational Model*

TraditionalVirtual (Canvas)Virtual (Acellus or Edgenuity)Blended
If you chose Blended, please specify when you would want your child at school. (Example: Middle School or High School student who wants to participate in on site band or athletics and complete other schoolwork at home)
Immunization Record 4 Year Old Program/Pre-K (Required by state of Oklahoma)

4 Doses DTP/DTap3 Doses Polio1 Dose MMR3 Doses HEP B2 Doses HEP A1 Dose Varicella
Immunization Record Kindergarten through 6th Grade

5 Doses DTP/DTaP4 Doses Polio2 Doses MMR
Immunization Record 7th through 12th

1 TDap Booster
Shot Records

Cancelof
Address of Residence*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Transportation Info*

Car Rider (Loop)Parent/Pick-UpWalkerBus RiderDay Care
If Daycare, which one?
Race*
Does this student have any degree of American indian Ancestry or have a CDIB Card?*

YesNo
CDIB Card (If Applicable)

Cancelof
Previous School Attended (If Applicable)
Date of Last Attendance (If Applicable)

MonthDayYear
Date
Legal Guardian #1 Name*

First NameLast Name
Legal Guardian #1 Relationship to student*
Legal Guardian #1 Social Security Number*
xxx-xx-xxxx
Legal Guardian #1 Phone*
Please enter a valid phone number.
Legal Guardian #1 Email*
example@example.com
Legal Guardian #1 Place of Employment & Phone Number
Legal Guardian #2 Name*

First NameLast Name
Legal Guardian #2 Relationship to student*
Legal Guardian #2 Social Security Number *
xxx-xx-xxxx
Legal Guardian #2 Phone*
Please enter a valid phone number.
Legal Guardian #2 Email*
example@example.com
Legal Guardian #2 Place of Employment and Number
Emergency Contact #1*
Emergency Contact #2*
Non-Household Information: List in order of notification preference. Any contact listed, or created on the parent portal, may pick up a student or be contacted in case of illness/emergency, if parent(s)/guardians are unavailable. *
School age siblings (Legal Name, Birthdate, Grade, Gender, and Building)*
Vision Conditions

ContactsGlassesOther
Hearing Conditions

Hearing LossHearing Aid(s)Cochlear implant(s)
Life threatening health conditions(s). Please check all that apply to this student. If he/she requires a Medical Management/Emergency Care Plan, please contact your school counselor.

AsthmaDiabetesSeizure DisorderAllergy requiring an epi-penHeart ConditionHemophiliaMental Health (History of at risk)Food AllergyOther
If you child will have medication at the school for any of the above conditions, please specify.
General Health Concerns (Not life threatening). Please check all that apply to this student.

ADDADHDAutism Spectrum DisorderMild Kidney/Bladder ConditionsMild Asthma (No inhaler at school)Mild Allergy (Other than seasonal allergies)GI ConditionIBSMental Health ConcernsMild Heart ConditionMigraine Headache(s)Physical DisabilityOther
Anything we need to know about the above information?
What is the primary language used in the home, regardless of the language spoken by the student?
Please check if your child qualifies for any of the following:

IEP504Gifted/Talented
My child has permission to attend field trips*

YesNo
My student may access Wewoka Schools Network and Internet under the regulations of Wewoka School's Policy.*

YesNo
I give consent for my child to be photographed for the yearbook, website, school social media pages, and/or newspaper. My child may be recorded in the classroom (video or audio) listed in sport's rosters, and listed in programs of any kind.*

YesNo
I give consent for my child to receive corporal punishment*

YesNoCall First
You may share my child's personal information with any open records request*

YesNo
I hereby attest that the above information is correct to the best of my knowledge. All things I have given Wewoka Public Schools permission for is signed here for authenticity.

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