SMITH COUNTY SCHOOLS

STUDENT ENROLLMENT FORM

IS YOUR CHILD CURRENTLY SUSPENDED OR EXPELLED FROM YOUR PREVIOUS SCHOOL

SYSTEM? _____________ NO ____________ YES
IS YOUR CHILD CURRENTLY PLACED IN AN ALTERNATIVE SCHOOL OR ANY OTHER TYPE OF
SPECIAL PLACEMENT? ______________ NO _____________ YES
Where choices are given, circle one. TODAY’S DATE: ____/____/_____
LEGAL NAME ______________________________________________ SEX: M F GRADE _____
Last First Middle
ENROLLMENT DATE ___/___/___ RACE: Asian Black Hispanic White Indian Other______
BIRTH DATE: ___/___/_____ SOCIAL SECURITY # __________________________
BIRTHPLACE: _______________________ MOTHER’S MAIDEN NAME ____________________
MORNING BUS #: ______ AFTERNOON BUS #: ______ MILES RIDDEN ON BUS: ________
CUSTODY: Both Mother Father Other: ___________________
MOTHER’S NAME: ________________________________________________________
911 HOME ADDRESS _________________________________________________________________
CITY ________________________________________ STATE _____ ZIP CODE __________
HOME TELEPHONE # ____________________ CELL PHONE # ______________________________
MOTHER’S EMPLOYER ______________________________________ PHONE _________________

FATHER’S NAME: ________________________________________________________

911 HOME ADDRESS (if different) _________________________________________________________
CITY ________________________________________ STATE _____ ZIP CODE __________
HOME TELEPHONE # ____________________ CELL PHONE # ______________________________
FATHER’S EMPLOYER ______________________________________ PHONE ________________
SCHOOL LAST ATTENDED ___________________________________________________________
IS YOUR CHILD IN: TITLE I (Remedial reading) YES _______ NO ______
SPECIAL EDUCATION (Resource) YES _______ NO ______
DO YOU OR YOUR SPOUSE WORK ON FEDERALLY OWNED PROPERTY? Yes ______ No ____

ARE THERE CUSTODY CONCERNS INVOLVING YOUR CHILD OF WHICH WE SHOULD BE AWARE?
Yes _______ No _______
LIST ANY PERSON NOT ALLOWED TO SEE YOUR CHILD OR CHECK YOUR CHILD OUT OF
SCHOOL
PERSONS TO CALL WHEN PARENTS CANNOT BE REACHED. LIST SOMEONE WITH A PHONE.
NAME ______________________________________ PHONE # _____________________
RELATION ________
NAME ______________________________________ PHONE # _____________________
RELATION ________

IF AN UNATHERORIZED PERSON COMES TO PICK UP YOUR CHILD, YOU WILL BE CONTACT4ED

FOR VERIFICATION. IF WE ARE UNABLE TO CONTACT YOU, YOUR CHILD WILL NOT BE
ALLOWED TO LEAVE SCHOOL, UNLESS A NOTE OR PHONE CALL IS PROVIDED BY YOU.

IF YOU CANNOT BE REACHED AND YOUR CHILD SHOULD NEED EMERGENCY TREATMENT BY A
PHYSICIAN OR HOSPITAL ATTENDANT, DO YOU GIVE PERMISSION FOR HIM/HER TO RECEIVE
MEDICAL ATTENTION? YES ________ NO _______

CHILD’S PHYSICIAN _____________________________________ PHONE # _________________________

DOES YOUR CHILD TAKE ANY MEDICATION ON A REGULAR BASIS? YES _______ NO _______
IF YES, PLEASE EXPLAIN AND GIVE ANY SPECIAL INSTRUCTIONS: ______________________
___________________________________________________________________________________________

LIST ANY INFORMATION WE NEED TO KNOW ABOUT YOUR CHILD (PHYSICAL/ MEDICAL
PROBLEMS, SUSPENSION, PROBATION, CUSTODY PROBLEMS, ETC…)
___________________________________________________________________________________________
___________________________________________________________________________________________

WHAT IS THE FIRST LANGUARE YOUR CHILD LEARNED TO SPEAK?

_____ ENGLISH OTHER ______________
WHAT LANGUAGE DOES YOUR CHILD SPEAK MOST OFTEN OUTSIDE OF SCHOOL?
_____ ENGLISH OTHER ______________
WHAT LANGUAGE DO PEOPLE USUALLY SPEAK IN YOUR CHILD’S HOME?
_____ ENGLISH OTHER ______________

PARENT SIGNATURE ____________________________________________________ DATE____/____/____