Enrollment Form (Page 2 of 2) in pdf

Student's name:

Please mark and answer all applicable questions below.

Does this student receive Special Education Services? _________

Does this student live outside of the city limits of the school of attendance?____________

If Yes, please indicate the distance this student is transported to the school of attendance. ___________

Bus Rider? __________ Pick-up at: ________________ Drop off at: _______________

Does this student have a parent actively in the military? _____________

What was your student's original date of enrollment into a state of Kansas school?

____________

(Can be an approx. date.)

Please list all children in the household who are 5 years of age and under.

Name

Birthdate

Name

Birthdate

Emergency Information

In case of emergency, we will attempt to contact parent/guardian first. In the event we cannot do this, please provide the name of a

relative or close friend that we my contact.

Emergency Contact:

Phone:

Relationship:

Emergency Contact:

Phone:

Relationship:

Emergency Contact:

Phone:

Relationship:

Doctor's name:

Phone:

Allergies:

List any Medical Comments/Considerations:

List any Medical Alerts:

Automated Phone Calling System - If called of an Evening, contact at phone number #: _____________________________.

If called before school, contact Mother at phone # __________________________ / contact Father at phone # _________________________.

Consent to Publish Photographs

I hereby give permission for images of my child, captured during school events through photographs and/or video, to be used

solely for the purposes of school promotional material and publications, and waive any rights of compensation or ownership

thereto.

Legal Parent/Guardian Signature

Date

District Directory Consent

I hereby consent to the printing of the current home address and telephone number in the District Directory.

Legal Parent/Guardian Signature

Date

Fees:

Outstanding Fees: __________

Lunch Balance: 0.00

All Students

Textbook Rental: $50 ______

Food Service: __________

High School Students

Vocational Fee: $50 _______

Preschool Fees: _________

*Technology Fee: $50 _______

Activity: $50 _______

Band: $15 ________

*Includes 8th Grade Students

Enrollment Form Page 2

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