Grove High School &= nbsp; &nbs= p; &= nbsp; Id#______________

Enrollment Form = = Home Room:______________

These fo= rms must be complete

&nb= sp;

STUDENT INFORMATION:=

Today’s date:____________ Grade Enrolling In:_ SSN:= ____________________ Current Age:

&n= bsp; = ;

Student’s Legal Name:______________________________________________= &= nbsp; &nbs= p; Date of Birth:

&n= bsp; = ; &n= bsp; = ; Last, &= nbsp; &nbs= p; &= nbsp; First &= nbsp; &nbs= p; Middle

Name student goes by (if different from above):_________ Place of Birth: &nb= sp; = M or F

Physical Address:_______________=

&nbs= p; &= nbsp; &nbs= p; Street Address = &nb= sp; 2 &= nbsp; &nbs= p; City &= nbsp; &nbs= p; State Zip &= nbsp; &nbs= p;

Mailing Address:__________________________= ___________________________________________________________________________= ___________________

(if different from above) &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; City &= nbsp; &nbs= p; State Zip

Home Phone:_______________________________= ___ E-Mail address:___________________________________________________________________=

FAMILY STRUCTURE:

Child Lives with: Both Parents [ ] Father [ ] &nbs= p; Mother [ ] Guardian [ ] Self [ ] Host Family [ ]

Please list the names of adults with whom = the child lives:

Name:_____________________________________= _________ = Relationship:__________________________ Home Phone:________________________

Employer:_________________________________= __________ = Wk Phone:____________________________ &nb= sp; Cell Phone:__________________________

Name:_____________________________________= _________ = Relationship:__________________________ Home Phone:________________________

Employer:_________________________________= __________ = Wk Phone:____________________________ &nb= sp; Cell Phone:__________________________

Non-Resident Parent Information (we will disclose information to this person unless you specify otherwise)

Name:_____________________________________= _________ = Relationship:___________________________ Home Phone:________________________

Address:__________________________________= __________ &= nbsp; Wk Phone:_____________________________ &n= bsp; Cell Phone:__________________________

Who has legal custody of this child? ___________= ____________________________________

Please list other children in the family:<= o:p>

Name:____________________________________<= span style=3D'mso-spacerun:yes'> Age:_____ Grade:_____ Name:____________________________________ Age:_____ Grade:_____<= /p>

Name:____________________________________<= span style=3D'mso-spacerun:yes'> Age:_____ Grade:_____ Name:____________________________________ Age:_____ Grade:_____

FOR THE HEALTH AND SAFETY OF SAID CHILD, t= his section MUST be completed with valid contacts.

List 2 neighbors or nearby relatives who w= ill assume temporary care of your child, and/or whom we can release your child = to if you cannot be reached, in case of an accident, sudden illness or possible early dismissal (i.e. power outage, icy weather)

Name:______________________________ = Relationship:_____________ Name:_______________________________ &= nbsp; Relationship:_____________=

Address:___________________________ &= nbsp; Home Phone:_____________ = A= ddress:_____________________________ Home Phone:_____________

Work Phone:_______________________ &= nbsp; Cell Phone:_______________ &nbs= p; Work Phone:_________________________ = Cell Phone:_______________

Is your child of Indian descent? &= nbsp; Y or N If= Yes, how much? _________________________ = ; Do you have a CD= IB card? &n= bsp; Y or N

Please Check the Ethnicity of your student= : (optional) White_____ Indian _____&n= bsp; Asian/PI _____ <= /span>Hispanic:_____ Black= :_____

&nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; Other (please write in) _______________________=

School student last attended: &= nbsp; Name:_________= _______________________________________________ Phone #:_________= ________________

&nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; Address:______________________________________________________<= /span>

Has student ever attended Grove School District before? Y or N If yes, When?______________ Grade Level:_

Date:_=          = Student Name:_____________________________<= /h2>

MEDICAL EMERGENCIES/ILLNESS

I understand that it is my responsibility= as a parent/guardian to provide transportation for my sick child, unless my ch= ild is seriously injured or seriously ill.

I, the undersigned, do hereby authorize officials of Grove Public Schools to administer emergency medical care/first aid to my child, when needed.

I, the undersigned, do hereby authorize officials of Grove Public Schools to contact directly the = persons named, and do authorize the named physicians to render such treatment as ma= y be deemed necessary in an emergency, for the health of said child.

In the event physicians, other persons na= med on this form or parents cannot be contacted, the school officials are hereby authorized to take whatever action is deemed necessary in their judgment, f= or the health of the aforesaid child.

I will not hold the school district financially responsible for the emergency care and/or transportation for sa= id child.

_&nbs= p;   Yes, I authorize emergency treatment  =             &nb= sp;           __= _    No, I DO NOT authorize emergency treatment=

I give my permission for the school nurse= or other designated school official to give my child:

Acetaminophen (Tylenol)        &= nbsp;       [     ]        Yes         = [     ]        No        &= nbsp; According to drug information, these medications are Rolaids            =             &nb= sp;            =             &nb= sp;            = [     ]        Yes         = [     ]        No        &= nbsp; Aspirin Free.

Signature of Parent/Guardian:____________________________________      Date:=

SPECIAL SERVICES:
Grove Public Schools has notified me of available special education services and programs.

My child [   ] has or [   ] has not had   past   [   ] learning, [   ] physical or [   ] emotional difficulties which may necessitate special education services:

If child has been evaluated please list

date:_    Name of School: Address of School:___

CORPORAL PUNISHMENT:

Grove Public Schools may use corporal punishment as a form of discipline. Corporal punishment will be administered with a wooden paddle and wi= ll not exceed three (3) swats.

_&nbs= p;   Yes, I give my permission to administer corporal punishment to my child.

_&nbs= p;   No, I DO NOT give my permission to administer corporal punishment to my child.<= o:p>

Signature of Parent/Guardian:=         &= nbsp;       Date:=

HANDBOOK:

I have received a copy of the student handbook along with this enrollment packet. I understand that it is my responsibility to read and comply with the rules and regulations as directed within the student handbook. = It is also my responsibility to have my child comply with the rules and regulatio= ns herein.

Parent/Guardian signature certifies recei= pt of Student Handbook of Guidelines and Policies for Students and Parents whi= ch includes district policy relating to adoption and implementation of drug prevention program for students.

Signature of Parent/Guardian:_=         &= nbsp;       Date:=

Signature of Student:= _        &= nbsp;       Date:        &= nbsp;           &nbs= p;

Date:    Student Name:

MEDICAL HISTORY MUST BE UPDATED YEARLY!

Is student on Medicare or Medicaid?&nbs= p;          Y or N           &= nbsp;      f yes, please list number:__

Immunizations: Verifiable information must be prov= ided before enrollment will be completed.

MEDICAL HISTORY:

Has your child had any of the following? List date if known.

Arthritis:_ Heart Condition:_ Rubella:_

Asthma: Hepatitis:_ Scoliosis:________= _

Birth Injury:________ Hyperactivity:_ Seizures:_=

Bladder: Infectious Disease:___ Serious Injury/Accident: _

Cancer:_ Kidney:___= _ Sickle Cell:____________________= _

Chicken Pox: Measles: Skin Disease:_=

Diabetes: Mumps:____= Stomach Disorder:_

Emotional Problems: Physical Handicap:________ Surgery: Adenoidectomy:_

Fractures:_ Pneumonia:__= _ Appendectomy:_____

Frequent headaches: Rheumatic Fever:= Myrinotomy:_

TB/TB Contact: Tonsillities(chronic): Tonsillectomy:

Weight Problems:_ Bleeding Disorders: Other:

Does child have hearing problems? = Y or N      = ;        Tubes in ears? Y or N    If yes, date:_________

Does child have frequent ear infections? Y or N&= nbsp;   Hearing aid? Y or N      = ; Name of Ear doctor:_

Does child have vision problems? Y= or N   Has child been seen by an ey= e Dr.? Y= or N

Date of last vision exam: =     Wear corrective lenses (glasses, contacts) prescribed? Y or N

Name of Eye Dr.:______

Date of last dental check-up:_=      Name of Dentist:_______

Please indicate if child wears orthopedic devices, prosthesis, etc:_

Please indicate any serious illness or physical disability; i.e. allergies, asthma, epilepsy, diabetes, heart disease, etc:=

=

Is your child able to participate in scheduled class activities (i. e. recess, physical education)? Y= or N

If No, please explain and, if indicated, provide wri= tten instructions from the child’s physician:<= /p>
= __________________

Does your child have sever reaction to wasp/bee/inse= ct stings?   Y or N      = ;     What treatment is necessary?_

Does your child have any food allergies? Y= or N   If yes, what foods?________________________

What type of reaction does your child have? (hives, breathing problems, vomiting etc):_

Does your child have any allergies to pollens or oth= er environmental irritants? Y or N

Please list irritants:_________________=

Does your child have medication allergies? Y= or N            =    Please list:

Is your child currently taking medication(s) Y= or N            =

Please list medication name, how much and how often:_

= ________

Child’s Physician:            = ; 1^st Choice:_&= nbsp;          Phone:=

   &n= bsp;            = ;            &n= bsp;            = ;       2^nd Choice:_&= nbsp;         Phone:=

Child’s Dentist:            &= nbsp;      ________= _       Phone= :

Hospital Choice Name:     ________________= _       Phone= :

   &n= bsp;            = ;            &n= bsp;   Address:___________=

Grove High School &= nbsp; &nbs= p; &= nbsp; Id#______________

Enrollment Form = = Home Room:______________

Today’s date:____________ Grade Enrolling In:_ SSN:= ____________________ Current Age:

&n= bsp; = ;

Student’s Legal Name:______________________________________________= &= nbsp; &nbs= p; Date of Birth:

&n= bsp; = ; &n= bsp; = ; Last, &= nbsp; &nbs= p; &= nbsp; First &= nbsp; &nbs= p; Middle

Name student goes by (if different from above):_________ Place of Birth: &nb= sp; = M or F

Physical Address:_______________=

Has student ever attended Grove School District before? Y or N If yes, When?______________ Grade Level:_

Date: Student Name:__

Is student on Medicare or Medicaid?&nbs= p; Y or N &= nbsp; f yes, please list number:____________________________________

Grove High School &= nbsp; &nbs= p; &= nbsp; Id#______________

Enrollment Form = = Home Room:______________

Today’s date:____________________ Grade Enrolling In:_______________ SSN:__= ______________________________ Current Age:______

&n= bsp; = ;

Student’s Legal Name:______________________________________________________________________= &= nbsp; &nbs= p; Date of Birth:________________________

&n= bsp; = ; &n= bsp; = ; Last, &= nbsp; &nbs= p; &= nbsp; First &= nbsp; &nbs= p; Middle

Name student goes by (if different from above):_____________________________________ Place of Birth:____________________________ &nb= sp; = M or F

Physical Address:___________________________________________________________________= ____________________________________________________

Has student ever attended Grove School District before? Y or N If yes, When?__________________________ Grade Level:_____________

Date:__________________________________________ Student Name:____________________________________________

Is student on Medicare or Medicaid?&nbs= p; Y or N &= nbsp; f yes, please list number:____________________________________

Today’s date:____________ Grade Enrolling In:_ SSN:= ____________________ Current Age:

Student’s Legal Name:______________________________________________= &= nbsp; &nbs= p; Date of Birth:

Name student goes by (if different from above):_________ Place of Birth: &nb= sp; = M or F

Physical Address:_______________=

Has student ever attended Grove School District before? Y or N If yes, When?______________ Grade Level:_

Date: Student Name:__