School Registration Form

Leola School District

Student Information Sheet
Additional documents for registration

Bring the following documentation to the school office.

• Original Certified Birth Certificate
• Original Social Security Card
• Current Immunization Form
Student Information
Student Legal Name

First NameLast Name
Nickname
Birth Date

MonthDayYear
Gender
Ethnicity
Preferred Language
What language do you prefer to receive communication?
Preferred Language
What language is most frequently spoken at home?
Preferred Language
What language did your child learn when he/she began to talk?
Preferred Language
Which language does your child most frequently speak at home?
Preferred Language
What language do you frequently speak to your child?
Grade
How does your child get home?

Bus RouteWalk/Ride BikeDaycareParent Pick upDrive
Student lives with:

Both parentsMotherFatherGuardian
Student of Active Military Parent
Yes or NO
Primary Residence Information
Home Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Residence Information (if different from above)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Contact
Parent/Guardian 1

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Parent/Guardian 2

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Emergency Contact

In the event that Parent/Guardian can not be contacted, provide a name of a close relative/friend that we may contact:
Name

First NameLast Name
Phone Number

Area CodePhone Number
Physician and Medical Information
Preferred Hospital
Please list any of the following: Current medications, Medication allergies, Food allergies, Chronic health concerns.

Special Services
Does your child have an IEP for special education services or a 504 accommodation plan?

YesNo
Food Service
Lunch Balance roll over to next year

YesNo
How to receive low or negative lunch balance:

EmailPaper copy sent home with studentText
I declare under the penalties of perjury that all information is true and correct, and that I am the legal parent/guardian & have legal rights to make educational decisions for this student.
Print Name
Signature of Parent/Guardian

Powered by Jotform SignClear
Today's Date

MonthDayYear
Date
Should be Empty:

Leola School District