2014 – 2015
MINNEAPOLIS JR / SR HIGH SCHOOL
Enrollment Information Form
Please complete one form for each student in Jr High or High School
STUDENT INFORMATION
Last Name
First Name
Legal Last Name
Middle Name
Legal First Name
Nickname
Legal Middle Name
Street Address
Preferred name
Mailing Address
Street Address, City, Zip
PO Box, Apt #, Suite, etc.)
###-##-####
(###) ###-####
Click to choose date
Home Phone
Date of Birth
Soc. Sec. #
(###) ###-####
Gender
M
F
May we contact you by text?
Yes
No
Phone # to text:
(###) ###-####
Grade Level 2014-2015: Click to choose grade
Student Cell Phone (opt)
English, Spanish, etc.
Primary language spoken at home
Special Education?
Yes
No
Race and Ethnicity: (Note: Both Part A and Part B of the question MUST BE answered.)
Part A:
Is this student Hispanic/Latino? (Choose only one)
No, not Hispanic/Latino
Yes, Hispanic/Latino (A person of Cuban, Mexican, Puerto Rican, Cuban, South or Central
American, or other Spanish culture or origin, regardless of race)
The above part of the question is about ethnicity, not race. No matter what you selected above, PLEASE CONTINUE TO
ANSWER THE FOLLOWING by marking one or more boxes to indicate what you consider your student’s race to be.
What is the student’s race? (Choose one or more)
American Indian or Alaska Native (A person having origins in any of the original people of North and South American
(including Central America), and who maintains tribal affiliation or community attachment)
Asian (A person having origins in any of the Far East, Southeast Asia, or the Indian subcontinent including, for example
Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam)
Black or African American (A person having origins in any of the black racial groups of Africa)
Native Hawaiian or Other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam,
Samoa, or other Pacific Islands)
White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa)
Last School Attended
Has student attended USD 239 in the past?
Yes
No Last school attended:
I give the school permission to allow video taping, recording, or publishing of any school event in which my student
participates.
Yes
No
Part B :
PARENT / GUARDIAN INFORMATION (student lives with)
Check One:
Father
Uncle
Step-Father
Other
First Name
Last Name
Parent/Guardian Last Name
Name of Employer
Employer
May child be released to this person?
Check One:
Mother
Aunt
Brother
###-##-####
Home Phone
###-##-####
Cell Phone
E-Mail E-mail address
May we contact you via E-Mail? Yes
No
Parent/Guardian First Name
###-##-####
Work Phone
Yes
No
Step-Mother
Other
First Name
Last Name
Parent/Guardian Last Name
Name of Employer
Employer
May child be released to this person?
Grandfather
Be specific
Sister
Grandmother
Home Phone ###-##-####
###-##-####
Cell Phone
E-mail
address
E-Mail
May we contact you via E-Mail?
Yes
No
Parent/Guardian First Name
###-##-####
Work Phone
Yes
No
NON-CUSTODIAL PARENT (student DOES NOT live with)
Name
Address
Relationship
Full name
City
Street Address, PO Box, etc.
Employer Name of Employer
Have custodial rights been severed?
Yes
City
Mother, Father, etc.
Home Phone
State
StateAbbrev
###-##-####
Zip
Zip
###-##-####
###-##-####
Work Phone
Cell Phone
No
Is this person entitled to reports? Yes
No
STUDENT NAME:
Student’s Name
CHILD CARE PROVIDER
Name
Child Care Name – If none, leave blank
Address
###-##-####
Phone
Street Address, City
OTHER INFORMATION
Does your child ride a bus?
Name
Yes
No
Address
Nearest Neighbor’s Name
If yes, please provide the following information:
Phone Number
###-##-####
Nearest Neighbor’s Address
Anyone who lives outside the city limits of Minneapolis needs to complete the following for the State transportation report:
Taking the most direct route from the school in which your child attends to your door, the number of miles to the nearest
tenth of a mile as shown on the odometer is: (over 5 miles can be indicated with 5+):
NAMES AND GRADES OF OTHER CHILDREN LIVING IN THE HOME
Name:
Name:
Name:
Name:
Name:
Click to Choose
Click to Choose
Click to Choose
Click to Choose
Click to Choose
Grade:
Grade:
Grade:
Grade:
Grade:
Name of other Child in Home
Name of other Child in Home
Name of other Child in Home
Name of other Child in Home
Name of other Child in Home
School:
School:
School:
School:
School:
Name of school attending, if any
Name of school attending, if any
Name of school attending, if any
Name of school attending, if any
Name of school attending, if any
INCLEMENT WEATHER
If school is closed early due to weather or an emergency, my child is to:
Go home as he/she usually does
Be picked up by me or by Name of other adult child can be released to
Ride regular bus route home
PARENTAL CONSENT FOR STUDENT ACTIVITY TRIPS
I give permission for my student to attend school-sponsored trips for which he/she is eligible. He/she will
be transported by a school vehicle and the trip will be sponsored by school personnel.
Yes
No
MEDICAL EMERGENCY INFORMATION
Preferred Hospital
Insurance Carrier
Phone
Policy #
Salina Regional, OCHC, etc.
Name of Insurance Carrier
Health or Physical Problems:
###-##-####
Policy Number
City of Hospital
City
Plan #
Plan Number
Diabetes, Asthma, etc.
Allergy, Tylenol, etc. If additional space needed, please attach or write on back
List ALL medications taken:
Nuts, Milk, etc.
Insect: Bee, Wasp, etc.
Allergies (please be specific):
Food:
Dust, pollen, etc.
Penicillin, Sulfa, etc.
Airborne:
Drugs:
Does your child wear eyeglasses/contacts: Yes
No
Does your child wear a hearing aid? Yes
Does your child utilize the aid of a prosthesis or other artificial device?
Yes
No
Specify:
No
In the event parents/guardians cannot be contacted, I hereby certify that all persons listed below are of legal age and may be contacted with regard to my
children. Further, I hereby give my consent for medical treatment deemed necessary by physicians designated by school authorities in conjunction with his/her
participation in a school-sponsored activity. I understand this authorization will only be enforced when I cannot personally be contacted and provide for immediate
treatment.
Name of alternate adult
Name
Phone:
Home
Cell ###-##-####
Relationship to Family/Student
Relationship
Work Phone ###-##-####
Other Information:
May child be released to this person?
Yes
No
Phone:
Home
Cell ###-##-####
Work Phone ###-##-####
May child be released to this person?
Yes
No
Other pertinent helpful information
Name of alternate adult
Name
Relationship to Family/Student
Relationship
Other Information:
Other pertinent helpful information
School personnel have my permission to secure necessary medical attention, including an ambulance. Office and nursing personnel have my permission to
exchange medical information with school personnel who work with my child. They also have my permission to release my student’s immunization information to
the Kansas Immunization Program for the purposes of assessment and reporting.
Parent/Guardian Signature:
Notary’s Signature:
WITNESS my hand and seal this
(Seal)
day of
, 20
.
STATE OF KANSAS, COUNTY OF OTTAWA