EkalakaPublicSchools

Student Enrollment Form

Enrollment Date

required

Student Last name

required

Student First Name

required

Student Middle Name

required

Student Grade

required

Student Gender

required

Student Birthdate

required

Student Place of Birth

required

Student Ethnicity

required

American Indian/Alaskan Native

Asian

Black or African American

Native Hawaiian/Pacific Islander

White

Name and Address of School Last Attended

required

Grade level at School Last Attended

required

Transportation: Arrival

required

Car

Walk

Bus

Other

Transportation: Departure:

required

Car

Walk

Bus

Other

Migrant:

required

Yes

Foster Child:

required

Yes

Do you live more than 3 miles from school or the nearest bus stop? If so, how far?

required

Does the student have any physical problems that may affect school attendance?

required

List any special programs/services received at the previous school:

required

Family information

required

Father

Mother

Legal Guardian

Father Last Name

required

Father First Name

required

Father Phone Number

required

Father Employer

required

Father Work Phone

required

Father Cell Phone

required

Father Physical Address

required

Father Mailing Address

required

Mother Physical Address

required

Mother Last Name

required

Mother First Name

required

Mother Phone Number

required

Mother Employer

required

Mother Work Phone

required

Mother Cell Phone

required

Mother Mailing Address

required

Legal Guardian: Last Name

required

Legal Guardian: First Name

required

Legal Guardian: Phone Number

required

Legal Guardian: Employer

required

Legal Guardian: Work Phone

required

Legal Guardian: Cell Phone

required

Legal Guardian: Physical Address

required

Legal Guardian: Mailing Address

required

Legal Guardian: Proof of Guardianship:

required

Court Order

Affidavit

Emergency Information: Medical Alert 1

required

i.e. Allergies, Asthma, Medical Conditions, etc.

Emergency Information: Medical Alert 2

required

i.e. Medications

Emergency Information: Medical Alert 3

required

i.e. Special Accommodations

Physician Name and Telephone Number

required

Hospital Preference

required

Any other Important Information:

Parent/Legal Guardian Signature

required

Please remember to bring a Birth Certificate and Immunization records to the office!

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