School Registration Ash Creek Elementary School 6460 E Hwy 181 Pearce, AZ 85625 520-824-3340 Date: Name Of Student: Gender, Home Address: Mailing Address (If different than above): Date of Birth: /_/ Place of Birth: Last School Attended: Present Grade: Was your child ever placed in a Special Education Program? YES__NO__ Reason, Ifyes, When and Where: Mother’s Name: : Father’s Name: Mother's Date of Birt |___Father’s Date of Birth: Mother’s Birth Place: Father’s Birth Place: Mother’s Occupation: ___ Father’s Oceupation: Name and Address of Employer(s)_—__ Mother’s Work #: 7 Father's Work tt Mother's Cell or Home #: __ Father's Cell or Home # Emergency Contact Person if parent can not be reached: ‘Name & Phone: Who can your child be released to? ‘What is the primary language used in the home regardless of the language spoken by the student? ‘What is the language most often spoken by the student? ‘What is the language that the student first acquired? Ethnicity/Race background: (per Federal Regulations effective July 1, 2010 its required that you fill in both Seetion A and B) Section A: (Check one) Hispanic/Latino ____ OR Non-Hispanie/Non-Latino____ Section B: (Check all that apply-regardless of ethnicity, atleast one ofthe following races MUST be selected) American Indian/Alaskan Native__Asian__ Black/African American__ White Native Hawaiian/Other Pacific Islander__ Signature of Parent or Guardian Date