Re-Enrollment Form

Re-enrollment Form

2025-2026 School Year
Student Information
Legal Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Will your child be returning for the 2024 - 2025 school year?*

YesNo
If no, list reason
Follow-up call requested*

YesNo

Parent/Guardian Information
Parent/Guardian

First NameLast Name
Relationship to Student
Parent/Guardian Phone
Parent/Guardian Email
example@example.com
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Contact One
Primary Contact 1 Name

First NameLast Name
Relationship to Student
Primary Contact 1 Phone Number
Primary Contact 1 Email
example@example.com
Primary Contact 1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Contact Two
Primary Contact 2 Name

First NameLast Name
Relationship to Student
Primary Contact 2 Phone Number
Primary Contact 2 Email
example@example.com
Primary Contact 2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Contact Three
Primary Contact 3 Name

First NameLast Name
Relationship to Student
Primary Contact 3 Phone Number

Area CodePhone Number
Primary Contact 3 Email
example@example.com
Primary Contact 3 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

English Language Learner
Student Primary Language:
Home Language Survey on File?

YesNo
Proof of Residency

Please attach an updated Proof of Residency if residency has changed. (Current utility bill, voter registration, lease agreement, etc. with current address)
Has your address changed? If yes, attach proof of Residency below.*

YesNo
Proof of Residency

Browse Files

Cancelof
Primary Contact 1 Signature

Clear
Primary Contact 1 Name

First NameLast Name
Primary Contact 2 Signature

Clear
Primary Contact 2 Name

First NameLast Name

Updated Emergency Information and Immunization Record Card
Child Name

First NameLast Name
Date

MonthDayYear
Date
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Date of Birth

MonthDayYear
Date
Gender
Mother or Guardian Name

First NameLast Name
Mother or Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother or Guardian Home Phone
Mother or Guardian Cell Phone
Father or Guardian Name

First NameLast Name
Father or Guardian Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father or Guardian Home Phone
Father or Guardian Cell Phone
I authorize the following individuals to collect my child from the facility if I cannot be located:
Name 1

First NameLast Name
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name 2

First NameLast Name
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name 3

First NameLast Name
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name 4

First NameLast Name
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
The following individual(s) may NOT remove my child from School:
Custody papers have been provided and are on file at the school?

YesNo
If Medical care is necessary, CALL:
Doctor Name

First NameLast Name
Doctor Phone Number
Doctor Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Hospital Name
Hospital Phone Number
Hospital Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I hearby give authority to any hospital or doctor to render immediate aid as might be required at the time for hi/her health and safety. It is understood by me that hte expence of htis service will be acceptable by me.
In case of injury or sudden illness, I request that this individual be called first:

First NameLast Name
Does your child have insurance coverage?

YesNo
Name of Insurance Carrier

Immunization Information

For information regarding current immunization requirements go to www.odh.ohio.gov Immunizations : Required Vaccines for Schools
One of these must accompany the EIIR card at all times (select all that apply):

Copy of current official documented immunization record attachedReligious Beliefs exemption form signed by parent/guardian attachedMedical exemption form signed by physician and parent/guardian attachedSigned Laboratory Proof of Immunity form attached
Is the child allergic to food or other substances? (If yes, describe symptoms, name foods or substances to be avoided and the procedure to follow if reaction occurs.)
Is the child usually susceptible to infections and, if so, what precautions need to be taken? (If yes, list precautions)
Is child subject to convulsions and what should be our procedure if one occurs? (if yes, specify procedure)
Is there any physical condition that we should be aware of and what precautions should be taken (heart trouble, foot problem, hearing impairment, hernia, etc.) (if yes, list precautions)
If you have answered "yes" to any of the above, please provide a written action plan in case of medical emergency for your student. Blank action plans are available at the front office.
Other Special Instructions:
This Emergency Information and Immunization Record Card is accurate and complete and was provided by:
Parent/Guardian Signature

Clear
Parent/Guardian

First NameLast Name
Date

MonthDayYear
Date
Should be Empty:

Student Information

Parent/Guardian Information

Primary Contact One

Primary Contact Two

Primary Contact Three

English Language Learner

Proof of Residency

Updated Emergency Information and Immunization Record Card

Immunization Information