Office Use Only
Student ID# ____________________Today’s Date ________________
Start Date______________________ Record Requested ___________
Entered IC____________ Lunch ______________ BC _____________
New Student Enrollment Form
Student Information (Please Print – All items in bold required)
Student Legal Name: ____________________________________________________________________________________________________
Legal Last
Gender: _____M _____F
Legal First
Middle
Nickname
Birthdate: _____/_____/_____ Birthplace: _____________________________________ Grade: _________
Month
Birth Country: ___________________
Day
Year
City
State
1 st Date Entered US School: : _____/_____/_____
Date Entered US: _____/_____/_____
Month
Day
Year
Month
Day
Year
Resident County:______________________________________
Student’s Primary Language: ___________________________________ Language spoken at home: _____________________________
Student Ethnicity: (Required)
Is this student Hispanic/Latino?
Yes or No (Spanish culture/origin, regardless of race)
(Circle one)
Student Race: (Required-check all that apply)
_____White
_____ Black/African American
_____Asian
_____Native American/Alaskan Native
_____Native Hawaiian/Other Pacific Islander
Kindergarten Only: Did this student attend preschool? Yes or No
Preschool Name: __________________________________________
(Circle one)
Did this student receive any special services at previous district: _____IEP _____ 504 Plan ____ Title I _____ESL _____Gifted & Talented
Former School Information (Please Print)
Has this student ever attended EBF Community Schools before?
Yes or No
If yes, when?_______________________________
(Circle one)
Please list the last school attended: ______________________________________________________Fax#: (_____) __________________
School Name
__________________________________________________________________________________ Phone #: (____) _________________
Address
City, State, Zip Code
Primary Household Information - Required (Parent/Guardian Residing with student)
_______________________________________________________________________________________________ (____) __________________
Physical Address
Apt/Lot#
City
State
Zip Code
Home Phone
_______________________________________________________________________________________________ ________________________
Mailing Address ( if not same as above)
Apt/Lot#
City
State
Zip Code
Resident County
Parent/Guardian Residing with Student:
Last Name: _____________________________ First Name: ___________________________ Relationship to Student: _________________
Gender: M or F
Cell Phone: (______)_____________________ Email: _________________________________Call Sequence: ________
Employer: ______________________________________________________________Work Phone: (________)______________________
Spouse of Parent/Guardian listed above and Residing with Student:
Last Name: _____________________________ First Name: ___________________________ Relationship to Student: _________________
Gender: M or F
Cell Phone: (______)_____________________ Email: _________________________________Call Sequence: ________
Employer: ______________________________________________________________Work Phone: (________)______________________
Please Continue on Back
Secondary Household - Parent/Guardian NOT Residing with Student Should mailings be sent to this household?
Y or N
(Circle on)
_______________________________________________________________________________________________ (____) __________________
Physical Address
Apt/Lot#
City
State
Zip Code
Home Phone
________________________________________________________________________________________________________________________
Mailing Address (if not same as above)
Apt/Lot#
City
State
Zip Code
Last Name: _____________________________ First Name: ___________________________ Relationship to Student: _________________
Gender: M or F
Cell Phone: (______)_____________________ Email: _________________________________Call Sequence: ________
Employer: ______________________________________________________________Work Phone: (________)______________________
Spouse of Parent/Guardian listed above and NOT Residing with Student:
Last Name: _____________________________ First Name: ___________________________ Relationship to Student: _________________
Gender: M or F
Cell Phone: (______)_____________________ Email: _________________________________Call Sequence: ________
Employer: ______________________________________________________________Work Phone: (________)______________________
Emergency Contact (please list someone other than parent/guardian)
Last Name
First Name
Relationship
Home Phone
Cell Phone
Call Sequence
Household Information
Please list the name(s) of all siblings who are school age or under age 5 residing in student’s household:
Last Name
First Name
Age/Grade
School
Does parent/guardian of student have an active military status? Y or N Which military service? __________________ Deployed? Y or N
(Please Circle)
(Please Cirlcle)
I affirm, to the best of my knowledge, that the above information is correct and that I will notify the school each time there is a change in any
of the information.
Parent/Guardian Signature ______________________________________________________________ Date _______/_______/_______
Vision Statement:
The Eddyville-Blakesburg-Fremont Community School district will provide a quality education in which
students become life-long collaborative learners and innovative problem solvers in a global society.
Revised 2/5/15
Office Use Only
Student ID# ____________________Today’s Date ________________
Start Date______________________ Record Requested ___________
Entered IC____________ Lunch ______________ BC _____________
New Student Enrollment Form