Student Registration Form - Bemidji Area Schools
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1STUDENT REGISTRATION FORM
BEMIDJI AREA SCHOOLS - ISD #0031
TODAY’S DATE___________________________
EARLY CHILDHOOD SCREENING: YES NO
MARSS # ________________________________
OPEN ENROLLMENT: YES NO HOME DISTRICT ______
OTHER ID #________________________
PLEASE PRINT ALL INFORMATION
DATE OF ENTRY
SCHOOL
GRADE
DOES YOUR STUDENT HAVE AN IEP?
PRIMARY PHONE:
YES
NO
STUDENT FULL LEGAL NAME (LAST, FIRST, MIDDLE)
GENDER
ARE YOU ACTIVE IN THE MILITARY
M / F
YES
NO
ADDRESS
CITY
ZIP CODE
COUNTY
DATE OF BIRTH
PLACE OF BIRTH - CITY & STATE
LAST SCHOOL ATTENDED
CITY
STATE
LAST DATE AT PREVIOUS SCHOOL
FATHER/GUARDIAN (LAST, FIRST, MIDDLE)
CELL NUMBER
EMPLOYER
WORK PHONE
MOTHER/GUARDIAN (LAST, FIRST, MIDDLE)
CELL NUMBER
EMPLOYER
WORK PHONE
SECOND PARENT’S ADDRESS (if different than above)
CITY/STATE
ZIP CODE
PRIMARY PHONE:
Race/Ethnicity of the CHILD (Circle ONLY ONE)
3 – Hispanic
1 - American Indian
2 - Asian or Pacific Islander
4 - Black, not of Hispanic Origin
5 - White, not of Hispanic Origin
Additional Race/Ethnicity categories are required
EMERGENCY CONTACT:
Check the box YES or NO in Part A below. More than one “yes” may be marked in Part
B.
_______________________________________________
Part A – Is the child Hispanic/Latino (choose only one)
RELATIONSHIP TO STUDENT:
_____ Yes
Hispanic/Latino
_____ No
Not Hispanic/Latino
_______________________________________________
Part B – What is the child’s race? (may choose more than one)
HOME # ______________________________________
YES
NO …...American Indian/Alaska Native
YES
NO …...Asian
CELL #
______________________________________
YES
NO …...Black/African American
YES
NO …...Native Hawaiian/Pacific Islander
WORK # ______________________________________
YES
NO …...White
ALLOW PICK UP:
YES
NO
LIST ALL CHILDREN IN HOUSHOLD UNDER 21
HANDICAPPED
LAST NAME
FIRST NAME
MIDDLE NAME
GENDER
BIRTHPLACE
BIRTHDATE
YES
NO
M / F
MM
DD
YY
ARE YOU LIVING WITH:
STUDENT LIVES WITH:
I GIVE PERMISSION FOR MY CHILD TO USE THE
BOTH PARENTS
INTERNET/NETWORK INDEPENDENTLY AT SCHOOL.
RELATIVES
FATHER ONLY
IN A HOTEL
MOTHER ONLY
IN A SHELTER
FOSTER PARENT
IN YOUR OWN HOME
GUARDIAN
PARENT/GUARDIAN SIGNATURE
DATE
OTHER _____________
IN FOSTER CARE
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