Revised 06/17/02 ENROLLMENT FORM
Cape Girardeau School District NO. 63
Alma schrader_____ blanchard_____ clippard _____ franklin_____ jefferson_____ cms_____ cjhs_____ chs_____
Student Name Grade Sex Date
Last First Middle Month Day Year
Student Address Phone
Number Street Apt. # City State Zip
Race Age Birthdate Birthplace
Month Day Year City State
Social Security # - - * Birth Certificate # Proof of Immunization Yes* No
*This information is strictly voluntary. Information *Please attach to health record
supplied will be used in supplying information to Medicaid.
Has this student attended preschool or daycare? No Yes If yes, where attended:
How will this student be getting home from school? Riding the bus Car Rider Walker
Using a Daycare van (What Daycare Daycare Phone# )
Is there anyone who cannot pick up this child? No Yes If yes, please list:
FAMILY HISTORY
With whom does the student reside? (check all that apply) Father Mother Guardian Other
Does the family reside in own house, rental house, or apartment with another family?*
_____with a person other than family?* in a temporary housing facility?* (* Principal/counselor
must complete enrollment addendum form if any starred items are marked)
Who has legal custody of student? (check all that apply) Father Mother Guardian Other
FATHER'S Name Address Phone
Employer Occupation Bus. Phone
MOTHER'S Name Address Phone
Employer Occupation Bus. Phone
GUARDIAN (If not living with either parent):
Name Relationship Phone
Address Employer Bus. Phone
Nature of Guardianship (Check one): Court Appointed Power of Attorney Informal
Has either the parent, guardian, or the child, been employed within the past three years (or are any of the aforementioned
currently employed) in some form of temporary or seasonal agricultural or agricultural-related work?
No Yes* (*If yes, principal/counselor must complete enrollment addendum form)
Father's Education (Check one): Elementary Some H.S. High School Some College College Degree
Mother's Education (Check one): Elementary Some H.S. High School Some College College Degree
Number of Children in Family (List names and ages)
Brothers
Sisters
Is the student currently involved with: DFS/Foster Care** DYS Juv. Office Probation/Parole
**If student is in foster care, send copy of this form to the business department located at the Administrative Office.
If any of above checked, name of Agency Contact Person Phone
Does the student use a language other than English? No Yes * (Language(s) )
(*If yes, principal/counselor must complete enrollment addendum form)
Is a language other than English used in the home? No _____Yes* (Language(s) )
(*If yes, principal/counselor must complete enrollment addendum form)
Please complete other side.
SCHOOL HISTORY Revised 06/17/02
Previous Cape Girardeau School(s) Attended:
School Name Grade(s) Year(s)
Previous schools attended other than Cape Girardeau schools:
School Name Address Grade(s) Year(s)
Has the student ever been referred or assessed by a school district for special services? No Yes
Name of school district which assessed student
Type of disability diagnosed
Does the student have a current Section 504 Plan? No Yes
Does the student have a current IEP? No Yes
Has the student ever received special services? No Yes
Has the student ever received services through a school district gifted program? No Yes
Is student currently suspended OR expelled from any school district? No Yes (Explain)
Has student ever been charged with or convicted of a felony? No Yes (Explain)
Has student ever violated a previous school district policy on weapons, alcohol, drugs, or willfully inflicted injury on another person? No Yes (Explain)
I attest that all the above information is current and correct. I further attest that the student named on this document resides at the address stated. I understand that submitting false information relating to residency is defined as a CLASS A MISDEMEANOR and submitting false statements regarding the student's previous discipline history as questioned above is defined as a CLASS D MISDEMEANOR. School districts are authorized according to the Missouri Safe Schools Act to file police reports for said violations. In addition, I understand that Missouri law requires that a student be properly immunized prior to being admitted to school. Finally, I understand that the ATTENDANCE POLICY of the Cape Girardeau School District states that any student who is absent from school or any class more than five percent in any semester is subject to withheld grades and loss of credit in affected courses. Furthermore, I understand that the student's attendance at the previous school is affected by the application of the Attendance Policy.
SIGNATURE Father Mother Legal Guardian
DATE
Revised 06/17/02 DEVELOPMENTAL AND HEALTH HISTORY
Cape Girardeau School District NO. 63
Student Name Sex Birthdate
Last First Middle Month Day Year
Parent(s) Name Phone
Were there any prenatal difficulties? No _____ Yes _____ (Explain)
Were there any problems at birth? No Yes (Explain)
Student met developmental milestones (crawling, walking, talking): within normal limits early delayed _____
Has student had any serious illnesses? No Yes (Explain)
Common Childhood Diseases and Dates Chickenpox Measles Mumps
Other
Has student had any serious accidents? No Yes (Explain)
Has student had any surgeries (operations) No Yes (Explain) ______
Does the student take daily medications at home? No Yes At school? No Yes Emergency Only? No Yes
Name of medication(s) and reason(s) for taking
PLEASE PROVIDE ALL DATES (MONTH/DAY/YEAR) FOR ALL IMMUNIZATIONS (If copy of immunization records is available, copy may be attached in lieu of writing in dates):
POLIO: (Last dose must be given after age 4) 1 2 3 4 5
DPT: (Last dose must be given after age 4) 1 2 3 4 5
HEPATITIS B #1: HEPATITIS B #2: HEPATITIS B #3:
MEASLES #1: MEASLES #2: TB TEST:
RUBELLA #1: RUBELLA #1: DT: HIB VACCINE:
MUMPS #1: MUMPS #2: TETANUS: OTHER:
OR
MMR #1: MMR #2:
OR Medical Exemption (Attach documentation) _____ Religious Exemption (Attach documentation) _____
Doctor's Name Phone # Date of last physical
Dentist's Name Phone # Date of last exam
Orthodontist's Name Phone # Date of last exam
Hospital Preference: Southeast Missouri Hospital Saint Francis Medical Center Other _____
EMERGENCY CONTACT PERSON(S): Phone Name Address Relationship Home Work
COMPLETE THE FOLLOWING REGARDING HEALTH CONCERNS THAT PERTAIN TO YOUR CHILD
Eyes: glasses (reading distance ) contacts crossed lazy eye difficulty seeing
Ears: frequent infections tubes hearing difficulty (explain)
Hearing aid – Right Left Wear at school? No Yes Other
Please complete other side.
Revised 06/17/02
Other Concerns: Nosebleeds Headaches Eating Sleeping Menstruation Bowel Bladder
Requires diapering? No Yes Requires catherization? No Yes Bedwetting
Skin Dental Neurologic Lungs Blood disorder Blood pressure
Provide additional explanation for conditions checked above
Special diet: Requires special health care (explain)
Other health information or concerns:
Does your child have:
Allergies No Yes Please list and describe type of allergy (drug, food, insect, pollen):
Has the allergy required emergency action in the past? No Yes
Comments:
Asthma No Yes Triggered by: Treatments:
Bee Sting Allergy No Yes Describe reaction:
Any difficulty breathing? Need emergency medication?
Diabetes No Yes Take insulin: No Yes Date Diagnosed
Comments:
Epilepsy/Seizures No Yes Describe seizure:
Date of last seizure: Medication
Is the student currently under a doctor's care for seizures: No_____ Yes_____
Name of doctor:
Heart Condition No Yes Describe:
Bone or joint problem No Yes Any physical restrictions?
Comments:
Condition that prevents
P.E. participation No Yes Describe:
Physician's verification provided:
IF STUDENT REQUIRES MEDICATION AT SCHOOL OR A CHANGE IN PE PARTICIPATION, PLEASE OBTAIN THE APPROPRIATE FORM IN THE SCHOOL OFFICE.
I GIVE MY PERMISSION FOR THE ABOVE HEALTH INFORMATION TO BE SHARED WITH APPROPRIATE SCHOOL PERSONNEL ON A CONFIDENTIAL HEALTH CONCERN LIST. YES_____ NO_____
SIGNATURE Father Mother Legal Guardian
DATE