HORNETS
Student registration 2022-2023
Student Information
Name
First Name
Middle Name
Last Name
Grade to be enrolled
Please Select
7th
8th
9th
10th
11th
12th
Address
Physical Address
Street Address Line 2
City, State, Zip Code
State / Province
Postal / Zip Code
County of Residence
Birthdate
/
Month
/
Day
Year
Date
Social Security #
Gender
Race
Primary Language Spoken at home
Mailing Address (If different from Physical Address)
Student Phone Number
Please enter a valid phone number.
RESIDENCY: Please choose which of the following situations the child or youth currently lives in.
House or Apartment with parent/guardian
Motel, Car, or campsite
Shelter or other housing
With Friends or family members
Living in inadequate housing (no heat, no water, mold)
Parent/ Guardian 1
Name
First Name
Last Name
Relationship to student
Address
Physical Address
Street Address Line 2
City, State, Zip Code
State / Province
Postal / Zip Code
Primary phone number
Cell Phone Number
Please enter a valid phone number.
Employer
Work Phone
Email Address
example@example.com
Parent/Guardian 2
Name
First Name
Last Name
Relationship to student
Address
Physical Address
Street Address Line 2
City, State, Zip Code
State / Province
Postal / Zip Code
Primary Phone Number
Cell Phone Number
Employer
Email Address
example@example.com
Work Phone
Emergency Contact Information
Emergency Contact #1
Relationship to child
Phone Number
Emergency Contact #2
Relationship to child
Phone Number
Additional Information
Please list the names and Grades of siblings
Transportation to/from school.
Car Rider
Bus Rider
Other
Bus Number
Is your student covered by Medical Insurance (this includes Medicaid and ARkids First)? If yes, please complete the following insurance information. If no, skip to the FERPA consent
Yes
No
Name of insurance
Policy #
Physician
Physician phone number
Please list any medical conditions for this child.
Please list any current medications.
FERPA Consent
Please select one of the following.
8th Grade
New/Re-enroll
Special Education
In Compliance with the Family Educational Rights and Privacy Act (FERPA) (20U.S.C. § 1232g; 34 CFR Part 99). I, (Parent/ Guardian) give permission for my child, (Student)’s personally Identifiable information/student education records to be disclosed to a Third Party billing Agent for the purpose of billing Medicaid and/or Private Insurance
(Parent/Guardian Name)
(Student First and Last Name)
Printed Name of Parent/Guardian
Parent/Guardian Signature
Clear
Today's Date
/
Month
/
Day
Year
Date
Does your student have internet access? If you answered yes, please complete questions 1 and 2. If you answered no, please complete question 3.
Please Select
Yes
No
1. What is your internet type?
Residential Broadband
Cellular Network
Hotspot
Community provided wi-fi
Satellite
Dial-up
Other
None
Unknown
2. What is your internet performance?
Few or no internet interruptions
Regularly experience interruptioins
3. If no internet access, what is your internet access barrier?
Not Available
Not Affordable
Other
New student information
If you are a returning student, you may skip to the parent/student signatures.
Have you ever been enrolled in the Harmony Grove School District?
If yes, what school year.
Last School Attended
Address of last school attended.
Phone number of last school attended
Does your child currently receive any special services such as:
Gifted and Talented
504 Plan
Speech
Special Education
ESL
Is your child currently expelled or suspended from another school? If so, state the reason.
Has your child repeated any grades? If yes, what grade?
Parent/ Student Signatures
Please initial each of the following, then sign and date.
1. I agree to allow Harmony Grove School District to photograph and/or video my child for new media releases, including the yearbook, during the current school year.
2. I certify that have received a copy of the Student Handbook for Harmony Grove Public Schools. (PDF handbook located below. Can also be found on the HGSD1.com website and will be passed out at registration.)
I certify that have read and agree to the terms and conditions of Student Electronic Device and Internet Use Agreement.
I certify that have read and agree to the terms and conditions for home use of the Chromebook computer provided by the Harmony Grove School District.
Parent/Guardian Printed Name
Parent Guardian Signature
Clear
Date
/
Month
/
Day
Year
Date
Student Printed Name
Student Signature
Clear
Date
/
Month
/
Day
Year
Date
Preview PDF
Submit
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