New Student Registration Form

STUDENT REGISTRATION FORM
STUDENT INFORMATION
Student Name

Legal First NamePreferred NameLast Name
Date of Birth

MonthDayYear
Gender
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Cellphone
Format: (000) 000-0000.
Email
example@example.com
OCCUPATION HISTORY
Occupation (optional)
Employer
Are you a veteran of the US Military?
Branch of Service
Rank at Discharge
Combat injuries
Date of combat injury

MonthDayYear
EMERGENCY CONTACT INFORMATION
Emergency Contact Name

First NameLast Name
Emergency Contact Phone 1
Format: (000) 000-0000.
Emergency Contact Phone 2
Format: (000) 000-0000.
Relationship
GUARDIAN or LEGAL REPRESENTATIVE INFORMATION
Is the student under 18 or does the student have a legal guardian or legal representative?If YES, please answer the following regarding their guardian or representative:
Guardian Name

First NameLast Name
Relationship
Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home or Work Phone
Format: (000) 000-0000.
Cellphone
Format: (000) 000-0000.
Email
example@example.com

MEDICAL INFORMATION

Rows	Disability/Diagnosis:	Date of Injury (If Applicable):	Briefly describe your diagnosis/disability as it relates to your adaptive needs.
1
2
3

Rows	Weak (L)	Weak (R)	Average (L)	Average (R)	Strong (L)	Strong (R)
Upper Body Strength
Lower Body Strength

Rows	Full (L)	Full (R)	Limited (L)	Limited(R)
Upper Body Range of Motion
Lower Body Range of Motion

Rows	YES	NO	DETAILS Use the space below to provide details about anything for which you checked YES.
Is any part of your body paralyzed?
Do you have altered hot/cold sensation?
Do you use American Sign Language?
Do you have difficulty speaking, communicating, or being understood?
Do you have difficulty remembering things?
Do you have difficulty following directions?
Do you become easily frustrated?
Are you ever a danger to yourself or others?

STUDENT REGISTRATION FORM