LITTLE WOUND MIDDLE SCHOOL REGISTRATION

1. Student's Grade *

2. Student's Full Name *

First Name Middle Name Last Name

3. Is student known by any other name? *

Yes, please enter other name below No

4. Student's also known as....

First Name Middle Name Last Name

5. Student's Date of Birth *

6. Place of Birth *

7. Tribal Agency Enrolled

8. Tribal Enrollment Number

9. Student's Father's Name

First Name Last Name

10. Father's Address

11. Father's Place of Employment

12. Student's Mother's Name

First Name Last Name

13. Mother's Address

14. Mother's Place of Employment

15. Who has custody of child while attending Little Wound School? *

Both Parents Above, go to question 19 Father Above, go to question 19 Mother Above, go to question 19 Other, complete questions 16-19

16. Name of person, other than parents, who will have custody of student while attending LWS?

First Name Last Name

17. Place of Employment of person who has custody

18. Relationship to Child? *

19. Bus Run (if known)

20. Address where child will be residing while attending Little Wound School. *

21. Home/Cell Phone Number: *

22. Employment Phone Number

23. Email address *

24. Previous School Attended *

25. Is student currently on an IEP for Special Education services? *

Yes No I do not know

26. Is student on a 504 Plan? *

Yes No I do not know

27. Did student participate in Gifted & Talented Program? *

Yes No I do not know

28. Is your child allergic to any Medicines? Foods? Bee Stings? *

Yes, list allergies below No

29. List allergies.

30. Does your child have any health problems? *

Yes, list health problems below No

31. Identify health problems

32. Who is the primary health provider for your child? *

33. In case of an emergency, name of person to contact: *

34. Telephone No. *

35. If 1st contact person cannot be reached, contact: *

36. Telephone No. *

List the first and last names of ALL the people who are allowed to check out your student from school.

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Participate in School Related Activities

I give my consent for my son/daughter to participate in all school related activities. The school personnel will do within their power to safeguard the health and well being of the student to participate in all school activities, but are not responsible for accidents beyond their control. In case of any accident or illness while the student is participating or in route to participate in a school activity, I give my permission and signed consent to emergency medical care, including emergency dental or minor surgery, if such procedures become necessary, while the studentis under jurisdiction of the Little Wound School.

Records Release

I give the proper authorities/personnel of Little Wound School the authority to acquire all necessary documents from various departments and agencies that are required to attend Little Wound School.

Counseling Services

I agree to the standard and normal practice that students are able to see a counselor, when it becomes necessary. for Little Wound School to provide any counseling session deemed necessary for my son/daughter.

Photo Release

All photographers taking photographs on school property or of school events or students work must obtain a signed release form from any student or staff member who is visibly recognizable in the photograph. Crowd scenes where no single person is the dominant feature are exempt.

These rules governs photographs intended for use in any school publication of marketing or a public relations nature, such as newsletters, brochures, yearbooks, promotional items, or other such material, including photographs used on the web. These rules are not in effect when photographs are taken of news events, but photographs taken for news purposes requires a release for reuse in marketing materials.

Internet User Agreement

I grant permission for my son or daughter to access networked computer services such as electronic mail on the Internet. I understand that individuals and families may be held liable for violations. I accept full responsibility for child’s use of the Internet.

Participate in Lakota Ceremonies

I give my consent for my child to participate in Lakota ceremonies; Inipi (sweat lodge), smudging/songs.

I agree to the "Participate in School Related Activities" *

Yes No

I agree to the "Records Release" *

Yes No

I agree to the "Counseling Release" *

Yes No

I agree to the "Photo Release" *

Yes No

I agree to the "Internet User Agreement" *

Yes No

I agree to the "Participate in Lakota Ceremonies" *

Yes No

Please type person completing this registration *

Please sign below: *

Clear

LITTLE WOUND MIDDLE SCHOOL REGISTRATION

STUDENT AND FAMILY INFORMATION

CONTACT INFORMATION

FORMER SCHOOL INFORMATION

STUDENT HEALTH

Attachments

AGREEMENTS