Harmony Grove High School

Harmony Grove Elementary School

Student Registration Form 2025-2026
Student Information
Name*

First NameMiddle NameLast Name
Preferred name of Student:
Only Complete this section if your student goes by a name other than their complete legal first name. For example "Lizzie" for Elizabeth.
Grade to be enrolled:*
Address*

Physical Address

Street Address Line 2

City State Zip CodeState / Province

Postal / Zip Code
County of Residence*
Birthdate*

MonthDayYear
Date
Social Security*
Gender*
Race*
Primary Language Spoken at home*
Mailing Address If different from Physical Address
Student Phone Number
RESIDENCY: Please choose which of the following situations the child or youth currently lives in: House or Apartment with parent/guardian Motel, Car, or campsite Shelter or other temporary housing With friends or family members (other than or in addition to parent/guardian) Living in inadequate housing (No heat, no water, mold infested)*

House or Apartment with parent/guardianMotel, Car, or CampsiteShelter or other temporary housingWith friends or family members (other than or in addition to parent/guardian.)Living in inadequate housing (No heat, no water, mold infested)
If you are living in Shared Housing, check all of the following reason that apply:

Loss of housingEconomic situationProvide care for a family memberLoss of employmentParent/ Guardian is deployedOther
Parent/Guardian 1
Name*

First NameLast Name
Relationship to Student*
Address*

Physical Address

Street Address Line 2

City State Zip CodeState / Province

Postal / Zip Code
Email Address*
example@example.com
Primary Phone Number*
Cell Phone
Employer
Work Phone
Parent/ Guardian 2
Name

First NameLast Name
Relationship to Student
Address

Physical Address

Street Address Line 2

City State Zip CodeState / Province

Postal / Zip Code
Email Address
example@example.com
Primary Phone Number
Cell Phone
Employer
Work Phone
Emergency Contacts

These are trusted individuals that can be contacted in the event a parent or guardian can not be reached. They are in addition to the parents or guardians.
Emergency Contact 1*
Relationship to child
Phone Number*
Emergency Contact 2*
Relationship to child
Phone Number*
Additional Information
Please list the names and grades of siblings.*
What is the primary method of transportation for your child?*

Car RiderBus RiderOther
Health Information
Is your student covered by Medical Insurance (this included Medicaid and ARKids)*

YesNo
*If yes, please complete the following information.
Name of insurance
Policy Number
Physician*
Phone Number*
Please list any medical conditions for this child*
Please list any current medications*
FERPA Consent
Please select one of the following:*

8th GradeNew/Re-enrollSpecial Education
In Compliance with the Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99) I, Parent Name* give permission for my child, Student Name* ’s personally Identifiable information/student education records to be disclosed to a Third Party billing Agent for the purpose of billing Medicaid and/or Private Insurance.
Printed Name of Parent/Guardian*
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Home Internet Survey
Does your student have internet access?*
What is your internet type?*

Residential BroadbandCellular NetworkHopSpotCommunity provided Wi-FiSatelliteDial-upOtherNoneUnknown
What is your internet Performance*

Few or no internet interruptionsRegularly experience Interruptions
If no, what is your internet access barrier?

Not availableNot affordableOther
New Student Information
Have you ever been enrolled in the Harmony Grove School District
If yes, what school year
Last School Attended
Address
Phone Number
Does your child currently receive any special services such as:

Gifted/Talented504SpeechSpecial EducationESL
Is your child currently expelled or suspended from another school If so state the reason? If so, please state the reason?
Has your child repeated any grades
Parent/ Student Signatures

Please initial each of the following. Then sign and Date.
1. I agree to allow Harmony Grove School District to photograph and/or video my child for news media releases including the yearbook during the current school year*
2. I certify that I have access to a copy of the Student handbook for Harmony Grove Public Schools. (Digital Copies available on the Harmony Grove Schools Website. Hard copies can be picked up in Elementary or High School offices).*
Student Electronic Device and Internet Use Agreement
3. I certify that I have read and agree to the terms and conditions of Student Electronic Device and Internet Use Agreement.*
Chromebook Home Use Agreement
4. I certify that I have read and agree to the terms and conditions for home use of the Chromebook computer provided by the Harmony Grove School District.*
5. I agree to allow my child's photograph to be posted on HGSD social media.*
ParentGuardian Printed Name*
Parent Guardian Signature*

Clear
Date*

MonthDayYear
Date
Student Printed Name*
Student Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Harmony Grove Elementary School

Student Information

Parent/Guardian 1

Parent/ Guardian 2

Emergency Contacts

Additional Information

Health Information

FERPA Consent

Home Internet Survey

New Student Information

Parent/ Student Signatures