Basic Student Information
Grade: ______WVEIS: ______Date: ______
PARENT/GUARDIAN: PLEASE FILL IN ALL BLANKS COMPLETELY. YOUR SIGNATURE IS REGUIRED ON THE BACK TO AUTHORIZE EMERGENCY CARE FOR YOUR CHILD.
Student’s Name: ______
LastFirstMiddle
Sex: ______Social Security: ______Special Education Program: LD, BD, MI, SP, Gifted, Other
Male or Female
Date of Birth: ______Place of Birth: ______
Home Phone Number: ______Unlisted _____No _____Yes
Cell Phone Number: ______
Native Language: ______(EN – English; SP = Spanish; Other ______)
Ethnic Group: ______(W – White; B – Black-non Hispanic; H – Hispanic; I – American Indian or Alaskan; A – Asian)
Type of Transportation to and from school: ______(Bus #, car rider, walker)
Location of Home / 911 Address ______County ______
Mailing Address ______City, State ______Zip Code ______
In the last years, have you moved into this area seeking employment: ______No _____Yes?
PARENT / GUARDIAN INFORMATION
Primary Guardian**: ______
LastFirst Middle Initial
**Whom the student lives with, attach custody papers if applicable:
Relationship to Student: ______Home Phone #______
Please list any person who should NOT pick-up your child from school: ______
Do we have a court order: ______Yes ______NO?
Employer: ______Work Phone #: ______
Spouse of Primary Guardian: ______
LastFirst Middle Initial
Relationship to Student: ______
Employer: ______Work Phone: ______
Other Parent (if applicable): ______
(Parent whom student is NOT Living with) LastFirst Middle Initial
Mailing Address: ______Phone #:______
State BOE Policy 126-94-4 Parent Rights 4.1 An educational agency or institution shall give full rights to either parent u nless the agency or institution has been provided with evidence that there is a court order; state stature, or legally binding document relating to such matters as divorce, separation or custody that specifically revokes those rights.
Other parent may be sent the following, unless you have provided the school with documentation that prevents this:
______Report Card ______Attendance letters ______Discipline Letters
COMPLETE EMERGENCY MEDICAL FORM ON THE BACK
IN THE CASE OF AN EMERGENCY THE SCHOOL WILL CONTACT THE PRIMARY GUARDIAN (OR SPOUSE) FIRST, LIST NAMES OF TWO OTHER PERSONS TO CONTACT IN THE EVENT YOU CANNOT BE REACHED.
______
Last NameFirst Name
Relationship to student: ______Day time phone number: ______
______
Last NameFirst Name
Relationship to student: ______Day time phone number: ______
In the event of illness or accident to a child (ren) of mine attending school, which in the judgment of the principal of the school would seem to demand medical attention. I hereby authorize the said principal to summon medical help at my expense if I cannot be reached by phone. I further authorize the principal to facilitate the child’s transportation to a place where appropriate medical aid can be reached, if in the principal’s judgment, such transportation is necessary. I would prefer that the principal call:
Dr. ______Phone: ______
Dr. ______Phone: ______
Signature: ______Date: ______
(Parent or Legal Guardian)
STUDENT’S HEALTH HISTORY
1. List only known allergies (Example: foods, bee stings, etc.)
______
2. List all medications student takes regularly:
______
At School: ______
STUDENTS MUST HAVE A CURRENT “ADMINISTRATION OF MEDICATION” FORM ON FILE AT SCHOOL FOR SCHOOL PERSONNEL TO GIVE MEDICATIONS.
At Home: ______
3. List all surgeries child has had since birth:
______
4. List date of last tetanus immunization: ______
5. List all current health problems” (Examples: Heart problems – murmur epilepsy/seizures, asthma, diabetes, chronic ear infections – tubes, eczema (or other skin problems), migraine headaches, ulcers (0r other stomach or digestive problems), urinary or bowel problems. List past problems if they still have a bearing on current health needs.
Current: ______
Past: ______
STUDENTS ARE NOT TO CARRY ANY MEDICATONS (PRESCRIPTION OR OVER-THE-COUNTER) AT SCHOOL. ALL MEDICATIONS ARE TO BE BROUGHT DIRECTLY, UPON ARRIVAL ON SCHOOL GROUNDS, TO THE PRINCIPAL OR HIS DESIGNEE.
Created November 2017