Author: Nita Main

MAR LEE SCHOOL
STUDENT REGISTRATION FORM
Date:____________________________
Student Name ___________________________________________________________________________________________
Last First Middle
Entering Grade ________ Gender:_____Male _____Female Resident School District ________________________________________
Ethnicity (Choose one) Not Hispanic or Latino ___ Hispanic or Latino ___
Race (Check one or more, regardless of Ethnicity) Caucasian ___ Hispanic ___ African-American ___ Asian___ Native American ___ Hawaiian/Pacific Islander___
Birthdate ________________________ Birthplace ___________________________________________
Month / Date / Year City / State
Address: _________________________________________________________________________________________
Number / Street Name City Zip
Main contact number _____________________________________________________
Email :___________________________________________________
Adult Female Residing in the Home :_____________________________________________________________________
Employed by : _____________________________________________ Work Phone # ___________________________
Adult Male Residing in the Home: ___________________________________________________________________
Employed by :_____________________________________ Work Phone # ____________________________
Parent Living Elsewhere : __________________________________________________________
Name
Address : _______________________________________________________ Phone __________________
Number / Street City / State Zip
Any parent active military Yes_______ No________ if yes, Name ______________________________
Enlistment date_________________
_____Army ______Navy ______Air Force ______Marines ______ Coast Guard

With Whom Does Child Reside Special Services your child received at the previous school
___B—Both Parents ___ Speech
___C—Father/Stepmother ___Learning Disabled
___D—Mother/Stepfather ___Social Worker
___E—Father Only ___Title I
___F—Mother Only
___H—Court Placed
___J—Relative- ___________
___K—Foster Home
___L—Divorced, Joint Custody OVER

DO NOT FILL OUT—THIS AREA FOR OFFICE USE ONLY
UIC # _______________________ Entry Date _______________________
Birth Certificate ____Y ____N Immunization Record ___Y ___N School of Choice ___Y ___N

OVER FOR MORE INFORMATION

Alternate Emergency Contact/ Pick Up Person
Emergency Contact #1 ______________________________________________________________________
Name
Relationship ____________________________________ Phone # __________________________________
Emergency Contact #2 ______________________________________________________________________
Name
Relationship ____________________________________ Phone # __________________________________
Emergency Contact #3 ______________________________________________________________________
Name
Relationship ____________________________________ Phone # __________________________________
Family Physician : __________________________________________________________________________
Office Phone # __________________________________
If School should dismiss early for any reason does student know where to go: ______Y ______N
MEDICAL CONDITIONS / MEDICATIONS
Please list any medical conditions of student and medications taken: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Medications must be provided by the Parent or Guardian and the office personnel have permission to administer medication as specified by the Physician to my child. An additional form is required.
____________________________________________________ _______________________
Parent / Guardian Signature Date
OTHER CHILDREN WHO RESIDE IN THE HOME
Name Birthdate Grade
________________________ ______________________ ________________
________________________ ______________________ ________________
________________________ ______________________ ________________
________________________ ______________________ ________________
Does your child attend a day care center or sitter after school? _________Y _____________N
If Yes, Name: ____________________________________________________________________________________