N.L. Dillard Middle School

N.L. DILLARD MIDDLE SCHOOL

255 Hatchett Road, P.O. Box 310, Yanceyville, N.C 27379

Student Registration Form

Name ______Grade ______

Last First Middle

Social Security Number: ______Date of Birth: ______Age: ______Sex: ______Race: (Circle one) American Indian Asian Black Hispanic White

Multiracial Other ______

Address ______Phone (____)______Apt. Or House Number Street Name City State Zip Code

Mailing Address (if different from above) ______

Directions to home ______

Student resides with (Circle one) Mother and Father Father Only Guardian

Mother and Stepfather Mother Only Grandparents

Father and Stepmother Other (specify) ______

Family Information

Mother/Stepmother/Guardian ______Phone______

Address ______

Employer ______Occupation ______

Work Phone (extension if necessary) ______

Father/Stepfather/Guardian ______Phone______

Address ______

Employer ______Occupation ______

Work Phone (extension if necessary) ______

Parent’s Marital Status (circle one) Married Separated Divorced Single

Total Number of Children: ______Older Brothers _____ Older Sisters ______Younger Brothers _____ Younger Sisters

Who else lives in the home? ______

Emergency Contacts (Other than parents/guardian)

Name ______Relationship to Student ______

Address ______Phone ______

Name ______Relationship to Student ______

Address ______Phone______

Health and Medical Information

Doctor’s Name ______Phone (_____) ______

Address ______

Dentist’s Name ______Phone (_____) ______

Address ______

Preferred Hospital ______

1. Does your child take any medications regularly? ______If yes, what type(s) of medication? ______

2. List any special health conditions/allergies your child may have: ______

______

3. Is your child’s physical activity restricted for any reason? If yes, please explain. ______

______

Academic Information

Name of Previous School ______Withdrawal Date______

Address ______

Phone ______

Contact Person ______

Reason for transfer ______

Please circle any special classes or services your child received:

L.D. Reading Written Language Math Speech/Language

EMD BED AIG 504 LEP

Other ______

Please provide grades from the most recent report card:

Language Arts ______Math ______

Science ______Social Studies ______

Health/P.E. ______Elective ______

Please provide the name of the Math course your child took last year and the final grade: ______

The curriculum for students at Dillard Middle operates on a 4-block schedule (Two 45 minute class periods constitute one block). One block is allocated for Language Arts; one block is allocated for Math; one block is allocated for Science and/or Social Studies; and one block is allocated for an elective course and Health/P.E. Elective courses are listed below. Please order elective courses according to preference by placing a “1” by first preference and “2” by second preference.

_____ A) Band – emphasizes basic skills, note reading and performance

_____ B) Career Explorations - explores the advantages and opportunities of approximately 150 professions, occupations, and future careers

_____ C) Art – explores visual arts

Person completing this form ______Relationship to student ______

I AUTHORIZE THE SCHOOL TO SECURE EMERGENCY SERVICES FOR MY CHILD AS NEEDED.

Parent Signature ______Date ______

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Office Use Only

_____ Immunizations complete _____ Enrollment Code ______

_____ Language Survey _____ SIMS # ______

_____ Internet Survey _____ Custody Paper provided _____ Birth Certificate/S.S. card