Pangburn High School
1100 Short Street, Pangburn, Ar 72121 www.pangburnschools.org (501) 728-3513
2025-2026 NEW STUDENT REGISTRATION FORM
This form is for first-time students enrolling in grades 7 through 12 at Pangburn High School.
Student Information
Student's Full Name
*
First Name
Middle Name
Last Name
Gender
*
Please Select
Female
Male
Grade
*
Please Select
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Students Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Social Security number
*
555-55-5555
Student's Birthday
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Student Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student Mailing Address (Only enter if different form student physical address.)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Who the Student Lives With
*
Please Select
Both Parents
Mother
Father
Mother & Step Father
Father & Step Mother
Grandparents
Legal Guardian
Copy of Custody Papers on file (if applies)
Please Select
Yes
No
Extra Curricular
Clubs for 2026sy
Student Council
FBLA
FFA
FCCLA
Spanish Club
Art Club
Library Club
NHS
Beta
Band
Choir
FCA
Ladies of Character
Sports for 2026sy
Archery
Cheer
Cross Country
Baseball
Basketball
Golf
Softball
TRAVEL INFORMATION
Travel To School
*
Bus
Drives Self
Parent/Guardian will pick up student
Walk
Travel From School
*
Bus
Drives Self
Parent/Guardian will pick up student
Walk
If Traveling by Bus What Bus Animal
Bird
Cow
Dino
Dog
Elephant
Monkey
Rabbit
Whale
Guardian/Parent Information
Guardian 1/ Mother Information
Guardian 1/ Mother Name
*
First Name
Last Name
Guardian 1/ Mother Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Guardian 1/ Mother Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Guardian 2/ Father Information
Guardian 2/ Father Name
First Name
Last Name
Guardian 2/ Father Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Guardian 2/ Father Name
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Information
Emergency Contact Name
*
First Name
Last Name
Relationship to Student
*
Please Select
Grandparent
Aunt
Uncle
Sibling
Family Friend
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address Of Person To Contact In Case Of Emergency
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Sibling Information
Sibling Name 1
First Name
Last Name
Birthday
-
Month
-
Day
Year
Date
Grade
Please Select
Does not attend school
Daycare
Pre K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Sibling Name 2
First Name
Last Name
Birthday
-
Month
-
Day
Year
Date
Grade
Please Select
Does not attend school
Daycare
Pre K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Sibling Name 3
First Name
Last Name
Birthday
-
Month
-
Day
Year
Date
Grade
Please Select
Does not attend school
Daycare
Pre K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Is Student a Multiple Birth
Please Select
Does not Apply
Twin
Triplet
Quadruplet
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Check out list/ Pick up list
Please list any individuals, other than guardians, who are authorized to pick up your student. Only the individuals listed below will be permitted to pick up the student from school (limit of three). All authorized individuals must present proper identification upon request.
#1 Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Student
Please Select
Grandparent
Aunt
Uncle
Sibling
Family Friend
#2 Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Student
Please Select
Grandparent
Aunt
Uncle
Sibling
Family Friend
#3 Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Student
Please Select
Grandparent
Aunt
Uncle
Sibling
Family Friend
As the parent/guardian, I hereby authorize the individuals listed to pick up my child from school at any time. PARENT/GUARDIAN SIGNATURE
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Consent forms from handbook
Digital copy of the handbook can be found on the school website under the red student handbook tab. https://www.pangburnschools.org/
Chemical Screening Consent Form (Handbook pages 129-132)
*
Yes
No
Student Electronic Device And Internet Use Agreement Form (Handbook pages 52-55)
*
Yes
No
Chromebook Use and Procedure Policy (Handbook pages 133-139)
*
Yes
No
Publication of Directory Information - Allow Military recruiters', institutions of postsecondary education, and potential employer's (Handbook pages 32)
*
Yes
No
Permission to display student photo on school website, Facebook, newspaper, and/or yearbook (Handbook pages 32)
*
Yes
No
Home/School Learning Compact (Handbook pages 147)
*
Yes
No
Attendance Policy- Students are not allowed to have more than 8 absences per semester. Parent and Guardian notes are NOT accepted. (Handbook page 23-27)
*
Yes
No
Student Signature
*
PARENT/GUARDIAN SIGNATURE
*
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Corporal Punishment
School Board policy and the laws of the State of Arkansas allow the use of corporal punishment as an option in the discipline plan. This form is provided to give you, the parent/guardian, the option of whether or not you will allow an administrator or certified staff member of Pangburn Public Schools to use corporal punishment as a discipline option for your child. A written notice will be sent home if your child receives corporal punishment.
Please check one of the options below to ALLOW or NOT ALLOW your child to receive corporal punishment by an administrator or certified teacher if such an action should become necessary.
*
ALLOW - Administer corporal punishment to my child when necessary.
NOT ALLOW - Do not administer corporal punishment to my child.
Contact Person
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
PARENT/GUARDIAN SIGNATURE
*
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DIGITAL EQUITY SURVEY
Does this child have Internet Access at home?
*
Yes
No
If there is no Internet Access, what is the reason this child does NOT have internet Access?
*
Not Available
Not Affordable
Other
Not Applicable
What type of Internet Access does this child have? (Select one of the following)
*
Residential Broadband
Cellular Network
Hotspot
Community Provided Wi-Fi
Dial-up
Other
None
Unknown
Is the Internet Performance acceptable for learning activities? (Select one of the following)
*
Yes - experiences very few or no interruptions in learning activities caused by poor internet performance in the primary place of residence
Sometimes - regularly experiences interruptions in learning activities internet caused by poor internet performance in their primary place of residence
No - unable to complete learning activities due to poor internet performance in their primary place of residence
Not Applicable
What type of device does this child use most often to complete learning activities away from school? (Select one of the following)
*
Desktop Computer
Laptop Computer
Tablet
Chromebook
Smartphone
None
Other
What is the source of this primary learning device?
*
District Provided
Personal
Other
Not Applicable
What is the child's access to this primary learning device? (Select one of the following)
*
Shared
Not Shared
Other
Not Applicable
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Student Residency Questionnaire
Student's Name
*
First Name
Last Name
Birthday
*
-
Month
-
Day
Year
Date
Person completing form:
*
Parent or guardian
Youth
Unaccompanied youth (a youth that does not live with a parent or guardian)
Other
Name of Person completing form:
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Please answer these questions about the student’s residency. The information you provide is confidential and protected by the law called the Federal Education Rights and Privacy Act. We use this information to decide which schools students should attend. We also use this information to make sure the rights of a child, youth or an unaccompanied youth are met based on alaw called the McKinney-Vento Homeless Assistance Act.
Is the student’s address a temporary living arrangement?
*
Yes
No
Is the student’s living arrangement due to loss of housing or financial hardship?
*
Yes
No
If the answer to any of the above is YES, please complete the following:
Where is the student identified above currently living?
In a motel or hotel due to loss of housing or financial hardship
In an emergency shelter, transitional housing facility, or abandoned in a hospital
Sharing another family’s house or apartment
In a car, park, trailer park (this does not refer to a mobile home (trailer) park, this refers to a type of camping ground for fifthwheel camper trailers or other types of movable campers), camping ground, street, public space, substandard housing(housing that does not meet modern standards of living), or abandoned building
In a bus or train station
Moving from place to place (couch surfing)
In a public or private place not meant to be used as a regular place for people to sleep
Other:
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Registration Information.
Birth Certificate, Social Security Card, Shot Record, Proof of Residency {utility bills (electric, water, cable, etc.) with point of service address and your name must be visible} This cannot be a shut off notice. Any Medical Documentation (If applicable) Documentation of Custody Agreements (If Applicable) Please bring a copy of each to the school office.
Primary Race
American Indian or Alaska Native (A person having origins in any of the original peoples of North and South America, including Central America, and who maintains tribal affiliation or community attachment)
Asian (A person having origins in any of the original peoples of Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam)
Black or African American (A person having origins in any of the black racial groups of Africa)
Native Hawaiian or Other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands)
White (A person having origins in any of the original peoples of Europe, Middle East or North Africa)
Hispanic or Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race)
ADDITIONAL RACES (check all that apply):
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Hispanic or Latino
Past School Information
Last School Attended:
Phone Number of Last School
Please enter a valid phone number.
Format: (000) 000-0000.
Has this child been expelled from school in any other school district or is the child a party to an expulsion proceeding?
Please Select
Yes
No
Does your student attend/participate or qualify for any of the following programs (check all that apply)
Gifted and Talented
Speech
IEP
504
Dyslexia Program
Is this child a dependent of an active or reserve member of a branch of the United States Armed Services?
Please Select
Yes
No
If this child resides in a household with an active or reserve member of a branch of the United States Armed Services
Please Select
Active Duty – US Army
Active Duty – US Marines
Active Duty – US Air Force
Active Duty – US Coast Guard
Active Duty – US Navy
Active Duty – National Guard
Reserves– US Air Force
Reserves– US Army
Reserves– US Marines
Reserves– US Air Force
Reserves– US Navy
Reserves– National Guard
Parents serve in multiple branches
Submit
Should be Empty: