Student Enrollment Form
Date
-
Month
-
Day
Year
Date
Grade
*
Student's Name
*
Student Last Name
Student First Name
Student Middle Name
Gender
Address
*
Street Address
Street Address Line 2
City
County of Residence
Postal / Zip Code
Primary Phone Number
*
Please enter a valid phone number.
Student's Date of Birth
*
-
Month
-
Day
Year
Date
School District where student resides
*
What is this student's race?
*
American Indian or Alaska Native
Asian
Native Hawaiian or other Pacific Islander
Black or African American
White/Caucasian
Is this student Hispanic/Latino
*
No, not Hispanic/Latino
Yes, Hispanic/Latino
Primary language spoken at home
*
English
Other
School Previously Attended
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LEGAL PARENT/GUARDIAN #1
(Where the student resides)
Legal Parent/Guardian #1 Name
*
Parent #1 Last Name
Parent #1 First Name
Parent #1 Middle Initial
Are you legally responsible for this student?
*
Yes
No
Relationship to student
*
Father
Mother
Guardian
Parent #1 Address (if different than above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent #1 Home Phone
(if different than above)
Parent #1 Cell Phone
Please enter a valid phone number.
Parent #1 Work Phone
Please enter a valid phone number.
Parent #1 Place of Employment
Parent #1 Email
*
example@example.com
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LEGAL PARENT/GUARDIAN #2
Legal Parent/Guardian #2 Name
Parent #1 Last Name
Parent #1 First Name
Parent #1 Middle Initial
Are you legally responsible for this student?
Yes
No
Relationship to student
Father
Mother
Guardian
Parent #2 Address (if different than above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent #2 Home Phone
(if different than above)
Parent #2 Cell Phone
Please enter a valid phone number.
Parent #2 Work Phone
Please enter a valid phone number.
Parent #2 Place of Employment
Parent #2 Email
example@example.com
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Other parent/guardian information (ie. step-parents, etc.)
Is there a current ORDER OF PROTECTION, NO CONTACT ORDER, or any other safety factors which concerns this student?
*
Yes
No
Student Lives With:
*
Father/Mother
Mother/Stepfather
Mother/Significant Other
Uncle/Aunt
Father Only
Father/Stepmother
Father/Significant Other
Aunt Only
Mother Only
Grandparents
Brother (guardian)
Uncle Only
Joint Custody
Grandfather Only
Sister (guardian)
Adult Student
Grandmother Only
Foster Parents
Guardian-Relationship to student (if applicable)
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Sibling Information
Please list ALL children in the family.
Sibling Name
First Name
Last Name
Gender
M
F
Age
School
Sibling Name
First Name
Last Name
Gender
M
F
Age
School
Sibling Name
First Name
Last Name
Gender
M
F
Age
School
Sibling Name
First Name
Last Name
Gender
M
F
Age
Gender
M
F
School
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Family Residence
The McKinney-Vento Homeless Assistance Act, reauthorized by Title X, Part C, of theNo Child Left Behind Act, requires school districts to remove any barriers tothe attendance, full participation, and success of students, Pre-K throughgrade 12, who lack a “fixed, regular, and adequate overnight residence.” Thefederal law includes a definition of who is considered “homeless,” or as morecommonly referenced “in transition,” for the purposes of the Act and,therefore, eligible for the rights and protections it provides.
CONFIDENTIAL INFORMATION
Based on the above definition, please indicate your child’s living situation below if: (1) this describes your child’s current living situation; OR (2) the student enrolling is not living with a parent or legal guardian.
*
Homeless Shelter (Victim Shelter or Youth Shelter)
Double-up or couch surfing due to economic hardship or loss of housing with family or friends.
Train or bus station, park or car
Motel/hotel
Campground
Abandoned apartment or building
Foster Care, if less than 6 months in the same placement
Does not apply
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Special Education
Has this student ever received any special education services?
*
Yes
No
Is this student currently receiving special education services?
*
Yes
No
Does this student currently have a Section 504 plan?
*
Yes
No
Has this student ever had a mental health or behavioral residential placement?
*
Yes
No
If yes to any of the above, please provide a copy of the current placement document.
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Health Information
Please note any pertinent medical information about this student
Does this student have any chronic health problems?
*
Yes
No
If Yes, please describe:
Does this student use an Epi-Pen or other emergency medication?
*
Yes
No
If yes, will it be at school?
List any allergies/sensitivities:
Please describe reaction:
List ALL medications (including over-the-counter) that the student will take at school (Medication/Treatment Authorization form required)
Medication #1
Medication #2
Medication #3
Does this student have a history of learning disabilities, ADHS/ADD?
*
Yes
No
If yes, please describe:
What additional health information should we know about your child?
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Emergency Contacts
If we are unable to contact you, please list two LOCAL emergency contacts that BRPS may notify and/or release this student to:
Emergency Contact #1
Last Name
First Name
Middle Initial
Emergency Contact #1 - Relationship to student
Emergency Contact #1 - Home Phone
Please enter a valid phone number.
Emergency Contact #1 - Cell Phone
Please enter a valid phone number.
Emergency Contact #1 - Work Phone
Please enter a valid phone number.
Emergency Contact #2
Last Name
First Name
Middle Initial
Emergency Contact #2 - Relationship to student
Emergency Contact #2 - Home Phone
Please enter a valid phone number.
Emergency Contact #2 - Cell Phone
Please enter a valid phone number.
Emergency Contact #2 - Work Phone
Please enter a valid phone number.
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Public Act 328
Public Act 328 (effective January 1, 1995)requires public school districts to expel any student who possesses a dangerousweapon in a weapon-free school zone or commits either arson or rape in a schoolbuilding or on school property (including school buses and/or other schooltransportation). A dangerous weapon isdefined as “a firearm, dagger, dirk, stiletto, knife with blade over three (3)inches in length, pocket knife opened by a mechanical device, iron bar, orbrass knuckles or other devices designed to or likely to inflict bodily harm,including, but not limited to , air guns, and explosive devices.”
Choose one of the following:
*
1. Has NOT been expelled from another school.
2. Has been expelled from another school (or has expulsion charges pending.)
3. Is currently under suspension from another school.
If you checked box 2 or 3, please explain the circumstances below:
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Directory Information
The Board designates as student “directory information” a student’s name, address, telephone number, date and place of birth, photograph, video and /or electronic images, major field of study, participation in officially recognized activities and sports, height and weight, if a member of an athletic team, dates of attendance, date of graduation, awards received, honor rolls, and scholarships. If you have any objections regarding the release of this information about your child, please notify the school your child will be attending in writing.
Parent Consent - (Check each box to consent)
*
In case of illness, accident, or injury serious enough to warrant immediate medical attention, I hereby give permission to transport the above named child to the nearest hospital. I understand I am responsible for any and all costs incurred.
The Board may establish online access for the parents or the eligible student to the student’s confidential academic and attendance records. Please be reminded that the account and confidential information about the student is only as secure as the parents or student keeps their information. The parent, eligible student, or unauthorized party will hold neither the District nor its employees responsible for any breach of this information.
I understand, for the health, safety, and/or educational needs of my child, information may need to be shared with individuals working with my child. Typically, this would include the building administrator, secretary, teachers, aides, counselors, school social workers, transportation staff, school nurse, and truancy program coordinator.
There may be an occasion for enrollment in a virtual class. I hereby give permission to allow my child to enroll in a class that is taught in that format.
Parent's signature
This form will need to be signed by hand and submitted to BRPS Central Office.
Submit
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