Family Registration Forms

Emergency Release and Contacts

Student Name*

First NameLast Name

Grade*

Student Cell-phone (optional)

Area CodePhone Number

Primary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian #1 Name*

First NameLast Name

Relationship to Student*

Home Phone

Cell Phone*

Work Phone

E-mail*

Please share Parent/Guardian #1 email address with the Parent Collaborative Representatives (PTO) so that I may receive communications directly from the Parent Collaborative.*

YesNo

Parent/Guardian #2 Name

First NameLast Name

Relationship to Student

Home Phone

Cell Phone

Work Phone

E-mail

Please share Parent/Guardian #2 email address with the Parent Collaborative Representatives (PTO) so that I may receive communications directly from the Parent Collaborative.*

YesNo

Emergency Contact Name*

First NameLast Name

Relationship to Student*

Home Phone

Cell Phone*

Work Phone

E-mail*

example@example.com

In addition to those listed above, please list all people authorized to pick up your child.

1. Name

First NameLast Name

Phone Number

Area CodePhone Number

Relationship to Student

2. Name

First NameLast Name

Phone Number

Area CodePhone Number

Relationship to Student

3. Name

First NameLast Name

Phone Number

Area CodePhone Number

Relationship to Student

4. Name

First NameLast Name

Phone Number

Area CodePhone Number

Relationship to Student

5. Name

First NameLast Name

Phone Number

Area CodePhone Number

Relationship to Student

How does your child usually get home?*

WalkCarSchool busCity bus

Medical Information

Primary Physician*

Phone Number

Preferred Hospital*

List Allergies

List Medications and indicate if they are taken at home or at school

Does your student qualify for Medicaid and/or does your student have a Medicaid account?*

NoYes

If Yes, what is the account number?

Resilience Charter School and/or the sponsoring school district may release and exchange my child’s confidential information to agencies of the State of Florida which would allow the school and/or district to verify Medicaid eligibility, bill Medicaid for reimbursable Certified School Match services referenced on my child’s individual educational plan (IEP) and receive Medicaid reimbursement for Exceptional Student Education (ESE) services it provides to my child while at school. I understand that my child will continue to receive services referenced on his/her IEP whether or not I give consent.

*

I authorizeI do not authorize

Is there any court order restricting access to the student and/or student records (for example, a custody order preventing a family member from checking the student out of school)? If yes, you must provide the school with a certified copy.*

YesNo