January 28, 2011 Re-enrollment of current students is now open for the 2011-2012 school year. BOTH this form and the Emergency Contact/Permission form on the reverse side MUST be completed and returned no later than February 16, 2011. We require a complete re-enrollment packet be returned for each individual student. Failure to return BOTH forms by the deadline date may result in the loss of your child’s place for next year! At this time we also accept new enrollment of siblings; preference is given to the siblings of currently enrolled students whenever possible. A sibling is defined as a child living in the same home and sharing the same guardian. Please Print Information YES, my child will be returning for the upcoming school year. NO, my child will not be returning for the upcoming school year.

Student's Name: Current Grade: Parent/Guardian’s Signature Grade in Fall of 2011:

Date of Birth:

Please complete the following for any siblings that you would like to begin attending this school next year for the first time. This section is for siblings only. New Enrollment of Siblings Student Name Date of Birth Current Grade Grade in Fall of 2011

If you have any questions about how to complete this form, please contact the Main Office at 570-282-5199. We appreciate your immediate attention to this matter and look forward to another great year!

Remember: this form is due by February 16, 2011

Emergency Contact/Permission
I/We understand that providing current emergency contact information is critical to the safety and well-being of my/our child. My/Our signature on this form certifies my/our understanding and commitment to provide updates (in writing) of any and all changes in contact information, within 24 hours of any change to the school administrative assistant/secretary and my child’s classroom teacher(s).

1. Name of Child: 2. Address:
Street Number and Name Apt. #

Age: City Family Email address:

Date of Birth: State

/ Zip


3. Home Phone: 4. Mother/Guardian: Address if different than above: Occupation: Cell Phone: 5. Father/Guardian: Address if different than above: Occupation: Cell Phone:


Check if Same as Above

Employer: Work Phone: Address:
Check if Same as Above

Employer: Work Phone:

6. Local Emergency Contacts: Adult persons other than parents/guardians (18 years or older) who may be contacted in the event of an emergency: Name: Name: Relationship: Relationship: Phone: Phone:

7. I/We hereby give permission to the staff of the Fell Charter School to secure emergency medical treatment by a qualified physician for the above named child while under their supervision: YES NO (circle one) 8. Name of child’s physician or health clinic: Address: Phone Number 9. Hospital preferred for Emergency Treatment: 10. Health Insurance Policy Name and Number: 11. Please list any special services your child has received in the last three (3) years: City State Zip

After-Hours Emergency Number

12. Please list any allergies:

Date of last Tetanus Shot:




13. Name(s) of Person other than Parent or Legal Guardian to Whom Child maybe released (must be 18 years or older) One name per line:

In the event that I/we can not be contacted and if my designated emergency contact is not available, I/we understand and agree that Fell Charter School will telephone 911 for emergency medical assistance and will follow their directives. Parent/Guardian Signature: Today’s Date:



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