Registration Form ELL - Chehalis School District

Registration Form ELL - Chehalis School District

R.E. BENNETT SCHOOL STUDENT REGISTRATION FORM
233 S. Market Blvd., Chehalis, WA 98532 (360) 807-7220 (360) 748-7256 Fax
1. PRIMARY HOUSEHOLD INFORMATION Informacion residencial (hogar del estudiante) (Home in which child resides)
Student Last Name
Student First Name
Middle Name
Grade(grado)
Gender (genero)
(Nombre del estudiante) (Goes By)
(primer nombre) (Goes By)
(Inicial o Segundo nombre)
¨Male ¨Female
(Masculino Femenino)
Student Last Name
Student First Name
Middle Name
Previous Last Names Used
(apellido) (Legal)
(primer nombre) (Legal)
(inicial o Segundo)
(Ha usadootros appellidos anteriormente)
BirthDate
Birth Place
(fecha de nacimiento)
(donde nacio)
STREET Address, City, State, Zip
(Direccion donde vive: Calle, Ciuidad, Estado y zona postal)
Ethnic Origin: Please check one (origen cultural)
¨Asian ¨Black ¨Hispanic ¨ White
¨American Indian ¨Other:
Home Phone (numero de telefone en casa)
.
¨ Unlisted (privado)
MAILING Address, City, State, Zip (Direccion Postal)
Has your child attended school in Chehalis before?
(anteriormente ha asistido a la escuela en Chehals)
¨ No ¨ Yes (si) Which School? (ccual escuela?)
2. SIBLING INFORMATION (Brothers or sisters enrolled in the Chehalis School District) (Informacio de hermanos que asisten
al distrito escolar de Chehalis)
Nombre
Name
1.
2.
3
Relacion:
Relationship
Escuela
School
Grado
Grade
3. GUARDIAN INFORMATION (Persons with whom child resides) (nombre del encargado)
1. Guardian Name: ¨Mr. ¨Mrs. ¨Miss ¨Ms. ¨Dr.(nombre y estatus del encargado casado, soltero, etc.)
Work Phone(numero del trabajo)
Cell Phone (cellular)
Pager
Email Address
Relationship to student: Please Check One (su relacion-marque aqui)
¨ Mother-madre ¨ Father-padre ¨ Step Parent-padrastro ¨ Grandparent-abuelo ¨ Guardian-encargado
¨ Relative-familiar (relationship to student-su relacion):
2. Guardian Name: ¨Mr. ¨Mrs. ¨Miss ¨Ms. ¨Dr.
Work Phone
(numero del trabajo)
¨ Foster Parent ¨ Other/otro: ________
(nombre y estatus del encargado)
Cell Phone (Cellular)
Pager
Email Address
Relationship to student: Please Check One: (su relacion-marque aqui)
¨ Mother-madre ¨ Father-padre ¨ Step Parent-padrastri ¨ Grandparent-abuelo ¨ Guardian-encargado
¨ Relative-familiar (relationship to student-su relacion):
¨ Foster Parent ¨ Other/otro: ______
¨ I hereby certify the above-named child resides within the boundaries of the Chehalis School District.
Yo declaro que el nombre arriba anotado si reside en los alreadedores de Chehalis.
¨ Student does not reside within the boundaries of the Chehalis School District, but Choice paperwork has been filed and approved (El estudiante no
reside en Chehalis)
Name of resident district/nombre del Distrito donde reside):
Parent/Guardian Name (Printed)
Nombre del padre/encargado deletreado)
For Office Use Only/Solamente
para la oficina:
Parent/Guardian Signature
(firmar el nombre en corrido)
Teacher:
Date Submitted:
District #:
Immunization Record Complete ¨ Yes ¨ No Non-Resident district (other than choice)
Room:
Entry Date:
4. EMERGENCY CONTACT INFORMATION: (En caso de emergencia) We will make every effort to contact parents or
guardians first. However if we are unable to reach you, please provide the names and numbers of other LOCAL persons usually
available during the school day. The persons will be called in the order you list them below. (Primeramente la escuela hara el mayor
esfuerzo en comunicarse con los padres/encargados. Si usted no se encuentra entonces sera necesario que nos facilite nombres y
numeros locales de personas que esten disponibles durante el horario escolar).
Name(nombre de emergencia)
Relationship to Student
City (ciudad)
(relacion con el estudiante)
Daytime Phone #
(Numero durante el dia)
1.
2.
5. SPECIAL CONCERNS/Alguna problema legal o de custodia: ¨ Legal ¨ Custodial ¨ Other
Please list medical concerns on the attached Medical History form/Por favor dejenos saber cual es su preocupacion/problema.
Explain any legal restrictions preventing non-custodial, second household parent(s) or others from
visiting school, having access to records, or removing your child from school. (Explique si hubiera
restrinciones que previenen a un Segundo hogar a visitar o recojer su nino en la escuela)
Ø
Are there any current Washington State restraining court orders? (Tiene alguna orden en la
corte del estado de Washington ¨ Yes/si ¨ No
Ø
Ø
If yes, who does the order restrain from the child? Si, entonces dejenos saber quien es restringido
¨Mother-madre ¨Father-padre ¨Other/otro La escuela tiene que tener copia del orden de restrincion.
The school MUST have copies of current court orders on file.
Please use the space below to explain/Por favor explique:
6. 2nd HOUSEHOLD INFORMATION-Informacion de un Segundo hogar (Parent/guardian NOT primary household)
Guardian Name: ¨Mr. ¨Mrs. ¨Miss ¨Ms. ¨Dr.(Nombre del encargado y su estatus; casado, soltero, etc.)
Home Phone
Work Phone
Relationship to student:
Pager
Cell Phone
Email Address
Send mail to this person (Report cards, bulletins, etc.)
STREET Address, City, State, Zip
¨ Yes ¨ No
MAILING Address, City, State, Zip
7. TRANSPORTATION TO AND FROM SCHOOL:
AM Bus Route #
PM Bus Route #
Pickup Location AM
Dropoff Location PM
¨ Walk/Ride Bike
¨ Private Auto
Time
Time
e
8. DAYCARE INFORMATION: Is the daycare provider listed below authorized to take this student out of school
for appointments or emergencies? ¨ Yes ¨ No
Name or Daycare
Street Address
Contact Person
Phone #
9. SPECIAL PROGRAMS:
Did this child receive special assistance at their previous school ?
¨ Yes ¨ No
¨ Gifted
¨ Other:
¨ Special Education/Resource
10. LAST SCHOOL ATTENDED:
Exit Date
Reason For Leaving
¨ Title I/LAP
School Name
School Address, City, State, Zip
.
District
Phone
11. AUTHORIZATION: The signature below acknowledges that all statements are understood and all authorizations as
indicated are approved as the parent/guardian of the student being registered.
Print Name
Signature
Date