Hays Lodgepole School District

Hays Lodgepole Schools Student Registration Form

46 Questions

Please complete the form as accurately as possible. If an item does not pertain to you or the child, please type "none" or "NA." When you have completed the form, choose the submit button at the end of the form.

Student Information

1) Student Name: First Middle Last

2) Grade

3) Birthdate

4) Age

5) Birth Place

6) Gender

7) Social Security Number

8) Ethnicity

9) Tribal Membership

10) Name of Previous School Attended

11) School Address

12) Reason for Transfer

Parent/Guardian Information

13) Parent/Guardian Name: First Middle Last

14) Mailing Address

15) Physical Address

16) Home Phone Number

17) Cell Phone Number

18) Email Address

19) Directions to your home.

21) Relationship to child

22) Emergency Contact: Name and Phone Number

Student Check Out Authorizations

Please list people authorized to check the student out of school.

23) Person 1 Name, relationship to child, phone number

24) Person 2 Name, relationship to child, phone number

25) Person 3 Name, relationship to child, phone number

26) Person 4 Name, relationship to child, phone number

27) Person 5 Name, relationship to child, phone number

Confidential Student Health History

The information that you provide about your child's health conditions may be disclosed to your child's teacher as well as other staff as needed to protect your child's health and safety at school. Please check any conditions that may apply and give additional information as indicated.

28) Allergies:

YES If yes, answer next 2 questions

NO If no, skip next 2 questions

29) What is the child allergic to?

30) What medication is used to treat any reactions?

31) Has your child ever been given a written prescription for epinephrine?

Yes

32) Does the child have diabetes?

Yes

33) If yes, what medications are used for diabetes?

34) Has the child ever experienced a seizure?

Yes

35) Date of Last Seizure

36) Current antiseizure medications

37) Does the child have hearing loss?

Yes

38) Does the child wear a hearing aid?

Yes

39) Does the child have vision impairment?

Yes

40) Describe vision impairment

41) Does the child wear glasses?

Yes

Other

Other Conditions

Please list other conditions which may affect your child's abilities in the classroom and that you want the teacher to be aware of, such as ADHD, ADD, BIPOLAR, AUTISM, ASPERGER'S, DEPRESSION, SCHIZOPHRENIA, ANXIETY DISORDER, or any other conditions.

42) Conditions

43) Medications for any diagnosis.

Signatures

Before the child attends school, a parent/guardian must complete a signature page at the school. You may also need to complete an Indian Student Eligibility Certification Form.

The school will need a birth certificate and a tribal membership or enrollment number if applicable.

44) Name of person filling out this form.

45) Your phone number

46) Today's Date

Hays Lodgepole School District

Schools

District

Staff Contacts

Athletics

Clubs/Groups

Student Enrollment

Jobs

Student Enrollment

Hays Lodgepole Schools Student Registration Form