Enrollment20 Form

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					                                                                                                DATE: ___________
                                      Elliott County Schools
                                          Student Enrollment Form

                                          (All Blanks Must Be Filled In)
Demographic Information
Student’s Legal Name ___________________________________________________________________________________
                        First                    Middle                    Last

Mailing Address ________________________________________________________________________________________


Physical Address _______________________________________________________________________________________


Home Phone _____________________________ Student Cell Phone ___________________________ Grade _____________


Date of Birth ______/_______/______ Place of Birth ___________________________ SS# ___________________________

Sex:    Male     Female


Student Email Address___________________________________________________________________________________
Last School Attended
Name of School Attending (circle)    ECHS        SHE       LES       IES

Previously Enrolled in Elliott County? Yes ___________        No ____________

Last School Attended and Address: _________________________________________________________________________
Transportation
Does this student ride a bus?                                                                           Bus # __________

Emergency Contacts: If you cannot be reached, whom do we call? This person would be authorized to pick up your child
from school. (Students will not be allowed to leave school with anyone who is NOT on this list. Students will NOT be signed
out based upon a telephone call. NO EXCEPTIONS!)

Name                                                Relationship                       Phone

_______________________________________             __________________________         ______________________________


_______________________________________             __________________________         ______________________________


_______________________________________             __________________________         ______________________________


_______________________________________             __________________________         ______________________________


_______________________________________             __________________________         ______________________________



                                                                                                   Please complete back page


                                                              1
                                                                                 ormation / Emergency Release

Health History

Family Doctor ________________________________ Physician Phone #_________________________

Insurance Co. Policy # ____________________________ Group # ________________________________

Is the student covered by Kentucky Medical Assistance? (Medical Card)    No     Yes: Card # _____________________

Are there any particular medical problems your child may be experiencing? (Please explain below)

o Physical Disabilities ____________________________________________________________________

o Allergies _____________________________________________________________________________

Asthma _______ Diabetes ________ Seizures ________ Hearing Difficulty _______ Kidney Problems_______

Current medications the student is taking ______________________________________________________

_______________________________________________________________________________________

Emergency Information and Treatment Release Form
From time to time during the school, various classes will go on field trips in connection with their class work.
In order to avoid repetition in securing your permission for these trips, this form has been devised to cover all trips
taken throughout the school year.

I do, hereby, give my permission for ______________________________________ to take part in any field trips or
activities sponsored by the school during the school year 20____ - 20____.

To serve your child in case of an accident of sudden illness either at school, on a field trip, or any school sponsored
activity, it is necessary that we have this release form signed.

I, the undersigned, do hereby authorize officials of the Elliott County School System to contact directly the person
named on this from, and do authorize the named physician(s) to render such treatment as may be deemed necessary in
an emergency for the health of the said child.

In the event that physicians, other persons named on this form, or parents cannot be contacted, the school officials are
hereby authorized to take whatever action is deemed necessary in their judgment for the health of the aforesaid child.

I will not hold the school district financially responsible for the emergency care and/or transportation for said child.


______________________________________________                                _____________________
Parent/ Guardian Signature                                                    Date




                                                             2
                                                                      Household Completed ____ (office use only)

                                     Elliott County Schools
                                      Household Enrollment Form
Primary Household                 (This is the address where the student resides)

Parent or Guardian (This is the primary parent/guardian that the student lives with)

Name __________________________________________________________________________________
                          First                 Middle                 Last
___Father     ____Mother      ____ Foster Parent    ____ Other (specify) ___________________________

Employer ______________________________________ Work Phone _____________________________

Cell Phone _____________________________ Email Address ___________________________________

Check to receive access to the following: ____ Portal (online access to grades, etc.) ____ E-mail notices

Parent or Guardian (This is the second parent/guardian that the student lives with)

Name __________________________________________________________________________________
                          First                 Middle                 Last
___Father    ____Stepfather ____Mother ____Stepmother ____Foster Parent ____Other (specify)______


Employer ______________________________________ Work Phone _____________________________

Cell Phone _____________________________ Email Address ___________________________________

Check to receive access to the following: ____ Portal (online access to grades, etc.) ____ E-mail notices
Students in Same Household            (List all students attending school in Elliott Co. ages 3 and up. List
additional students on a separate sheet of paper)

1st Student’s Legal Name __________________________________________________________________
                            First              Middle                 Last

SS # __________________________ DOB _____________ Grade ________ School _________________

2nd Student’s Legal Name _________________________________________________________________
                           First              Middle                 Last

SS # __________________________ DOB _____________ Grade ________ School _________________

3rd Student’s Legal Name _________________________________________________________________
                           First              Middle                 Last

SS # __________________________ DOB _____________ Grade ________ School _________________



                                                         3
                                 Elliott County Schools
                            Secondary Household Enrollment Form

Secondary Household

Parent or Guardian (This is the parent/guardian that the student does not live with)


Name __________________________________________________________________________________
                         First                Middle                Last
___ Father    ____ Mother    ____ Foster Parent   ____ Other (specify) ____________________________



Employer ______________________________________ Work Phone _____________________________


Cell Phone _____________________________ Email Address ___________________________________


Check to receive access to the following: ____ Portal (online access to grades, etc.) ____ E-mail notices


Parent or Guardian (This is either the second parent/guardian that the student does not live with)


Name __________________________________________________________________________________
                         First                Middle                Last
___Father    ____Stepfather ____Mother ____Stepmother ____Foster Parent ____Other (specify)______



Employer ______________________________________ Work Phone _____________________________


Cell Phone _____________________________ Email Address ___________________________________


Check to receive access to the following: ____ Portal (online access to grades, etc.) ____ E-mail notices




                                                       4
Student Name: _______________________
Parent Name: ________________________



Directions to the home:

___________________________________________
___________________________________________
___________________________________________
_______________




Nearest Neighbor:

___________________________________




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