Warren Local School District Student Admission Form To be completed by parent or guardian

Transcription

1 Student Admission Form To be completed by parent or guardian Which School are you Enrolling? WE LH WMS WHS Grade: Student s Legal Name: Last First Middle Date of Birth: _ City of Birth: Gender: M F (mm/dd/yy) Student Address: Mailing Address: (if different) address for Parent Portal: Is Student a resident of WLSD? Y N Has Student previously attended WLSD? Y N Previous School Attended: Has Student been expelled from previous school? Y N Racial/Ethnic Categories (select only 1) Hispanic? Y N White, non-hispanic Black, non-hispanic Asian or Pacific Islander Multiracial American Indian or Alaskan Native Does Student participate in any of the following programs? Free or Reduced Meals Gifted Education Is Student on an IEP? Y N Special Education ETR provided? Y N 504 Plan IEP provided? Y N I certify that all the information of the student enrollment form is true and correct to the best of my knowledge. Parent/Guardian Signature Date

2 Parent/Guardian and Emergency Contact Information Student Name: Parent/Guardian: Relationship: _ Resides with: Y N Address: Home Phone: Cell Phone: Work Phone: Parent/Guardian: Relationship: _ Resides with: Y N Address: Home Phone: Cell Phone: Work Phone: Other Parent Information: Relationship: Name: Resides with: Y N Address: Home Phone: Cell Phone: Work Phone: Emergency Contacts: Name Relationship Phone Number 1. _ 2. 3.

3 Student Health History Student s Name: Gender: M F Date of birth: / / Student receives regular medical treatment for the following: Allergies Cancer Migraines Asthma Cystic Fibrosis Neuromuscular Disorder ADD/ADHD Diabetes Seizure disorder Autism Depression Sickle Cell Anemia Behavior concerns Ear problem/hearing difficulty Skin conditions Birth/Congenital Emotional Concerns Speech problems malformations Headaches Traumatic Brain Injury Bone/Muscle/Joint Heart problems Vision problems problems Hemophilia Glasses Contacts Blood problems Juvenile arthritis Other Bowel/bladder problems Lead poisoning Other No Medical Conditions Allergies: Y N If yes, Type Reaction School Restrictions or Actions: Please list any medications the student takes on a regular basis: Medication Dosage Reason _ Do any health and/or medical conditions require school restrictions, modifications, and/or intervention? Y If yes, please explain on back. N Does the student require any special procedures and/or treatment for their health condition(s)? Y N If yes, please explain on back. Please indicate any other information about your child s health that you think would be helpful for the school to know on the back of this form. ***If your child develops any health conditions in the future, please contact the school nurse to update this form. /_/_ Form completed by Relationship Date Information on the back of this form: Y N

4 Restrictions, modifications and/or interventions: Special procedures and/or treatment: Other health information:

5 Release of Records Consent To: _ (previous school) (Street Address) Phone Number: Fax Number: (City, State, Zip) Requesting records for: _ (Student s Name) / / (Date of birth) From: Warren Local Schools 220 Sweetapple Rd_ Administration Building _Vincent OH Phone: Fax: We are requesting the following information/records for the above named student: All personally identifiable data on file. The following records only: _ Reason for request: To aid in making present and future educational decisions. Other: With the understanding that the district cannot assume responsibility for the confidentiality of educational information disclosed, I authorize you to release educational information regarding the above named student in the manner indicate. (Signature of parent/guardian or student, if 18 or older) (Date)