2026-2027 RETURNING STUDENT REGISTRATION FORM

2026-2027 RETURNING STUDENT REGISTRATION FORM

This form is for returning students in grades 7th through 12th at Pangburn High School. Please see Mrs Erika in the high school office IF your contact information has changed.
Student Information
Student's Full Name

First NameMiddle NameLast Name
Grade for the 2026-2027 school year
Who the Student Lives With
Students Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guardian / Parent Information

Please update all phone numbers
Guardian 1/ Parent 1's Name

First NameLast Name
Guardian 1/ Parent 1's Name Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Guardian 1/ Parent 1's Name Email
example@example.com
Relationship to Student
Guardian 2/ Parent 2's Name

First NameLast Name
Guardian 2/ Parent 2's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Guardian 2/ Parent 2's Email
example@example.com
Relationship to Student
TRAVEL INFORMATION
Travel To School
Travel From School
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)
Chromebook Use and Procedure Policy (Handbook pages 133-138)
Publication of Directory Information - Allow Military recruiters', institutions of postsecondary education, and potential employer's (Handbook pages 35)
Permission to display student photo on school website, Facebook, newspaper, and/or yearbook (Handbook pages 35)
Home/School Learning Compact (Handbook pages 144)
Attendance Policy- Students are not allowed to have more than 8 absences per semester. Parent and Guardian notes are NOT accepted. (Handbook page 26-30)
Bell to Bell No Cell. (Handbook page 91)
STUDENT SIGNATURE
PARENT/GUARDIAN SIGNATURE
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.
Contact Person

First NameLast Name
Contact Person Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
PARENT/GUARDIAN SIGNATURE
Health History Form

2026-2027 School Year
Giving Medication

The following NON-PRESCRIPTION medications, Acetaminophen (Tylenol), Ibuprofen (Advil), Tums, & topicals (triple antibiotic,hydrocortisone, etc). I understand that the school nurse (or trained staff) will determine if the medication is needed, and will administer the age/weight appropriate dose. Generic forms of the medications may be used. I understand that unexpected adverse reactions may occur from any medication, and hereby release the Pangburn School District and its employees from any liability related to such unexpected reactions.

*As a general rule these medications are not given before 10:00 a.m. or after 2:00 p.m. to reduce the possibility of over- medicating any student. All over-the-counter (OTC) non-prescription medications are available to students on a limited basis. Students who require frequent doses of these OTC meds must bring their own supply, and a parent must come in to discuss the use of OTC medications. Benadryl is given ONLY in cases of acute allergic reactions – no other OTC allergy medications are provided by the school.
Can medication be given to your student?
Parent/Guardian Signature
In the event of a medical emergency and an ambulance is called, EMS will determine the appropriate care
What type of insurance does your student have?
With parental consent, the school district can seek federal Medicaid reimbursement for the cost of the health services the school district provides to children who are eligible for Medicaid. In order to seek the federal Medicaid funds for reimbursement, the school district must disclose information from your child’s education records to Medicaid and Medicaid billing agencies.

In compliance with the Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99) In compliance with the Family Education Right to Privacy Act (FERPA) (20 USC § 1232G; 34 CFR Part 99).I give permission for any child to participate in the School Immunization Clinic. I understand that the appropriate Arkansas Department of Health consent forms will be provided for my consideration prior to the clinic.

I will notify the school of any change in address, phone number, emergency contact, or child’s health status. I understand that the information on this form may be released to appropriate School District employees and emergency personnel in order to facilitate health care for my child
Parent/Guardian Name

First NameLast Name
Parent/Guardian Signature

Does student have a current medical diagnosis of any of the following conditions? Check all that apply. *(Please ask your doctor to provide written orders for management of this medical condition at school.)

Rows	Yes	No
ADD/ADHD *(Diagnosed by a doctor)
ASTHMA *(Diagnosed by a doctor)
BONE/JOINT PROBLEMS
DEPRESSION
DIABETES *(Diagnosed by a doctor)
EAR PROBLEMS (Hearing aids)
HEART PROBLEMS *(Diagnosed by a doctor)
HYPERTENSION
FREQUENT HEADACHESMIGRAINE HEADACHES *(Diagnosed by a doctor)
SEIZURE DISORDER *(Diagnosed by a doctor)
VISION (Glasses, Contacts)
OTHER HEALTH CONCERNS *(Diagnosed by a doctor)(Cystic Fibrosis, Celiac Disease, Hemophilia, etc.)

Does your student have any allergies or a history of allergic reactions?
If yes, please list the allergy and describe the reaction experienced. Example: (Penicillin – rash; Peanuts – swelling and difficulty breathing).
Does your student take any medication
What medication(s) is your student is currently taking? Please list each medication along with the current dosage and frequency of use.
OTHER HEALTH CONCERNS
Student Electronic Device And Internet Use Agreement Form (Handbook pages 59-60)
Should be Empty:

2026-2027 RETURNING STUDENT REGISTRATION FORM

Student Information

Guardian / Parent Information

TRAVEL INFORMATION

Consent forms from handbook

Corporal Punishment

Health History Form