FLAT ROCK ELEMENTARY
STUDENT INFORMATION SHEET
HOMEROOM TEACHER _______________________________
Please PRINT clearly
Student’s Full Name
Student’s Date of Birth
Student’s Race
Student’s Social Security Number
Student’s Parent/Guardian Name(s)
Student’s Home Telephone
Student’s Mailing Address
*City/State/Zip Code
Student’s Residence Address
Mother/Guardian’s Name
Mother/Guardian’s Employer
Mother /Guardian’s Work Telephone
Mother /Guardian’s Cell Phone
Mother /Guardian’s Home Address
Mother /Guardian’s Home Telephone
Bus Number or Car rider
Father/Guardian’s Name
Father /Guardian’s Employer
Father /Guardian’s Work Telephone
Father /Guardian’s Cell Phone
Father /Guardian’s Home Address
Father /Guardian’s Home Telephone
PARENT/GUARDIAN EMAIL
Please list life threatening illnesses or allergies.
Please list Emergency Contact Numbers
Name
Relation
Telephone
Name
Relation
Telephone
Name
Relation
Telephone
CUSTODY CONCERN
FLAT ROCK ELEMENTARY SCHOOL
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LEGAL RESIDENCY
HOMEROOM TEACHER________________________
Student’s Name _______________________________________Grade___________
By signing this statement, I declare that I am a legal resident of Anderson School District
Three and my child is eligible to attend Flat Rock Elementary School by living in the Flat
Rock Elementary attendance area.
Parent or Guardian Signature
Date
Students who do not reside in Anderson County School District Three must pay out-of-district tuition or
qualify by some other reason. Forms are available at the District Office for these purposes.
Out-of-district tuition may be charged to parents retroactively if the above statement is discovered to be
false.
Students who reside in Anderson County School District Three but do not reside in the Flat Rock
Attendance area must have permission to attend Flat Rock School from the principal and superintendent.
A conference must be arranged with the principal before the request can be considered. Priority is given
to students that live in the Flat Rock boundaries. Space is dependent on class size and grade level
enrollment. Permission must be granted each year even if the student(s) attended Flat Rock Elementary in
the previous year(s). This is granted on a year by year basis.
My child (children) attended Flat Rock in the previous school year.
Please circle YES or NO
Name(s) of child (children) ______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
Bus Number or Car rider __________________________________
(How does student get home?)
FLAT ROCK ELEMENTARY SCHOOL
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CUSTODY INFORMATION
Student________________________________Grade_______Teacher___________________
Bus Number or Car rider _____________________
PLEASE CHECK ONLY ONE BOX:
___________My child does not have any custody issues that need to be addressed.
___________My child HAS custody papers on file at school.
___________My child HAS custody issues, but does NOT have papers on file at school.
I am aware that without papers on file legally my child may be released to both
biological parents.
Due to custody issues, my child MAY be released to the following people:
1.
2.
3.
4.
5.
Due to custody issues, my child MAY NOT BE RELEASED TO THE FOLLOWING PEOPLE:
1.
2.
3.
4.
5.
Additional Comments:
FLAT ROCK ELEMENTARY SCHOOL
3
COMMUNICATION INFORMATION
HOMEROOM TEACHER_____________________________
Bus Number or Car rider _____________________________
EMAIL
If you would like to receive school news by email, please complete and return.
We request that you print carefully and clearly in order for us to get your address
in our system correctly. If you would like to include your business, community
organization, or church, please include at the bottom of this sheet.
Through the year, please keep your email current with us.
Name of Student__________________________________
Grade___________________________________________
Teacher_________________________________________
Email Address___________________________________________
Other:
Person/Organization
Email Address
Person/Organization
Email Address
ANDERSON SCHOOL DISTRICT THREE
FLAT ROCK ELEMENTARY SCHOOL
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Parent Permission Form
HOMEROOM TEACHER_________________________
1. Please read the information below.
2. Fill in your child’s name.
3. Sign in the appropriate space to indicate that you DO or DO NOT give permission for the
activities described.
4. RETURN SIGNED FORM TO YOUR CHILD’S TEACHER.
As a parent/guardian of ___________________________________________, a student at
Flat Rock Elementary School, I DO hereby give my permission for my child’s name, a
recognizable picture and/or school work to be used by Anderson County School District
Three in the following manners:
1. In school-sponsored publications, including but not limited to newspaper
and newsletters.
2. On the school/district website concerning school-related activities.
3. In other media, including but not limited to newspapers and television,
in articles or news stories pertaining to the school/district including
recognition for student awards and achievements.
I understand that by providing permission for name, recognizable picture and/or school work to
be used as noted above, I am NOT giving permission for the District to release any information
regarding my child’s discipline record or special education records pertaining to my child.
I agree to hold harmless and indemnify Anderson County School District Three, its Board of
Trustees, employees, and agents should any claim arise regarding the use of my child’s name,
photographic image and/or school work as noted above.
I DO give my permission: ______________________________________
Signature
Date
As a parent/guardian of ___________________________________________, a student at
Flat Rock Elementary School, I DO NOT give my permission for my child’s name, a
recognizable picture and/or school work to be used by Anderson County School District
Three. I DO NOT wish for my child to be identified or photographed for publications
and/or display with regard to any related activity.
I do NOT give my permission: __________________________________
Signature
Date
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