Elementary School Registration Form

Student Name

Sex

Last

First

Middle

Address

Phone

Birthdate

Place of Birth

Father's Name
Mother's Name

Marital Status:

Married

Separated

Divorced

Widowed

Single

Full names and ages of the children in the family:

Name

Age

Others living in the home:
Has your child received Special Services at his/her former school(s)?

yes

no

If yes, what was the service?

Chapter 1

Speech

Resource

Handicapped

Special Placement

Behavioral Concerns

Other

School last attended:

(Please give name of school, street address and state.)

How many schools has your child attended as of this date?

What language is spoken in the home?

For Office use only

Grade

Classroom Placement

Date Entered:

Bus #

Pick-up

Time

Return Trip

Birth Certificate

Immunization Record

Required Immunization

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