SAMPLE XYZ Charter
REGISTRATION FORM (Lottery Draw and/or Enrollment)
SCHOOL YEAR 20__ – 20__
Student ID#
_______________
__________________________________________________________________________________________
LAST NAME FIRST
NAME MIDDLE
NAME
-wp_files/image001.gif){kind=small}
SCHOOL:
___________________________GRADE: ____________ SSN# _____________________________
SEX: ______ RACE:
______ BIRTHDATE: /
/ Age as of September
1, 20XX______________
ADDRESS:
________________________________________________________________________________
CITY:
PHONE:
_________________________________________BIRTHPLACE:
____________________________
FIRST
PARENT/GUARDIAN: ____________________________________RELATION:
_________________
ADDRESS:
________________________________________________________________________________
CITY:
_________________________________________STATE: __________ ZIP:
______________________
HOME PHONE:
_______________________________ WORK PHONE: ______________________________
PLACE OF EMPLOYMENT: _________________________________________________________________
SECOND
PARENT/GUARDIAN: ________________________________ RELATION: __________________
ADDRESS:
________________________________________________________________________________
CITY:________________________
HOME PHONE:
__________________________________ WORK PHONE: ___________________________
PLACE OF EMPLOYMENT:
_________________________________________________________________
EMERGENCY CONTACT
NAME:___________________________PHONE: __________________________
DOCTOR PREFERENCE:
__________________________________ PHONE: __________________________
HOSPITAL
PREFERENCE:_________________________________ PHONE: __________________________
PREVIOUS
SCHOOL(S) ATTENDED: _________________________________________________________
Is your child
transferring from another school district?: (Yes or No) If Yes, from what
district? ______________
Bus Transportation Information: Will your child be using bus
transportation to get to school? (Yes or No)______
TO THE PARENT: The
information asked above is needed as a permanent school record of your child
and will be used by school personnel.
This is to certify the above information is correct. I, the undersigned, do hereby authorize
officials of this school to contact directly the person named on this form, and
do authorize the above named physician to render such treatment as may be
deemed necessary in an emergency, for the health of said child. In the event physician, other persons named
on this form, or parents cannot be contacted, the school officials are hereby
authorized to take whatever action is necessary in their judgment, for the
health of the aforesaid child. I will
not hold the school district financially responsible for the emergency care
and/or transportation for said child.
________________________________________________ _________________________________________
Parent or Guardian Signature Date
II. 3