Flippin Middle School by tuKkt86

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									                                                       Flippin Middle School
                                                      REGISTRATION FORM
                                                                                                                 Enrollment Date: ___________________
Student Name _____________________________________________________________
                      Last          First          Middle

Mailing Address _________________________________________________________________________                    □ (check here if information is new for 2010-11)
                Number & Street                        City          Zip Code

Transportation       __ Walker        __ Bus Rider __ Car Rider

Home Phone _(____)__________________Birth Date _______________ Gender M F                                       Entering Grade             6 7 8
                                                month/day/year    (circle one)                                                           (circle one)
Social Security Number ______________________________________

Parent/Guardian Email Address ________________________________________________

Name of Father /Guardian: ______________________________________ Phones: Home:________________Cell:_____________
(circle one)
Home Physical Address _____________________________________________________________________ Work Phone _(_____)_____________________
                  Number & Street                     City                      State     Zip Code
Employer __________________________________________________________            Occupation _____________________________________________________


Name of Mother / Guardian: _______________________________________________Phones: Home: _______________Cell:_____________
(circle one)
Home Address _____________________________________________________________________ Work Phone _(____)___________________
                Number & Street                  City            State   Zip Code
Employer ___________________________________________________ Occupation ________________________________________________


Name of Stepmother / Stepfather: _________________________________ Phones: Home: ________________Cell:________
(circle one)
Home Address ____________________________________________________________________ Work Phone _(____)___________________
               Number & Street                   City            State   Zip Code
Employer ___________________________________________________ Occupation ________________________________________________

Name(s) of sibling(s) currently attending this school: _________________________________________________________________________
Student Lives With □ Father           □ Mother       □ Step-father      □ Step-mother       □ Legal Guardian □ Other (check all that apply)
Please mark any category (please mark one) which applies to your family:
___ lack fixed, regular, and adequate nighttime residence
___ sharing housing due to loss of housing or economic hardship
___ living in motels, hotels, trailer parks or camping grounds due to lack of alternative adequate housing
___ living in emergency or transitional housing
___ none of the above

Ethnicity (check one):        Primary Race (check only one):                               Additional Race (check all that apply):
____ Hispanic                 ____ American Indian/Alaska Native                           ____ American Indian/Alaska Native
____ Non Hispanic             ____ Asian                                                   ____ Asian
                              ____ Black                                                   ____ Black
                              ____ Hispanic                                                ____ Hispanic
                              ____ Native Hawaiian/Other Pacific Islander                  ____ Native Hawaiian/Other Pacific Islander
                              ____ White                                                   ____ White

Is a language other than English spoken in your home? □ Yes □ No                      If yes, what language is spoken? _______________

Have you ever attended Flippin Public School? □ Yes □ No             If so, when? _______________________________________

If you are transferring please check one: __ public school __ Private school ____Home School ___other (describe) _________________
 ___ Alternative School (if yes, why?) ______________________________________________________________________________________
School transferring from:_________________________________________               _______________________________________________
                             Name of School                                              Address

Has the student ever been expelled from school? □ Yes □ No
If yes, what was the reason for the expulsion and the date? ______________________________________________________________________


SPECIAL PROGRAMS:
Was your son/daughter identified as a Gifted and Talented student in a former school? □ Yes □ No
Did your child have a 504 Plan? □ Yes □ No If yes, please specify: ________________________________________________________
Did your student receive Special Education services in a former school? □ Yes □ No If yes, please circle.

HEALTH EMERGENCY INFORMATION–PLACER COUNTY OFFICE OF EDUCATION

If Parent or Guardian cannot be reached call

1. (Name/Phone #s: Home/Work/Cell)___________________________________________________________________________________

2. (Name/Phone #s: Home/Work/Cell)___________________________________________________________________________________

Physician Name ____________________________________________________ Phone: ________________________________

*********************************************************************************************************************

I hereby authorize the school nurse, school principal or other person designated by him/her to administer Tylenol to

___________________________
Student Name

As needed for elevated temperature (100.6 degrees) or generalized discomfort.
An attempt will be made to contact parent/guardian for any child who has a temperature greater than 100.6 degree,
vomiting, or acute pain.
In consideration of the above action by the school employee, I hereby waive, release ad relinquish any claim which I might
have individually or on behalf of my child against the above named school employee and/or the Flippin School District or
its agents, servants, and employees arising out of administering Tylenol or the supervision thereof.

________________________________________________                                                  ______________
   Signature of Parent/Guardian                                                                    Date


Any medication other than Tylenol must be accompanied by a written authorization from the parent or legal guardian that
relieves the School Board and its employees of civil liability for damages or injuries resulting from the administration of
medication to students in accordance to Policy 4.35. Medication Consent Forms are available in the school office.

********************************************************************************************************************
Please check the following items if they pertain to your child:

     1.    There are no known health problems 
     2.    Known eye condition or defect in vision                     Wear glasses            Glasses to be worn at all times 
            Contact lenses                          Requires preferential seating            Date of last exam______________
            Under care of Dr. (name/phone)_______________________________________________________________________
            Comment_________________________________________________________________________________________
     3.    Known hearing problem  Uses hearing aid  Presently under care of Dr. (name/phone)_______________________
           Comment_________________________________________________________________________________________
     4.    Subject to any condition which may result in classroom emergency, such as Seizures  Fainting spells  Diabetes 
           Asthma  Allergies  Allergic reactions to bee stings  Heart Condition  ADD/ADHD  Other ______
           List Medication prescribed___________________ Dosage ________________For (diagnosis)_____________________
           Does the drug need to be taken during school hours? Yes  No  _______________________________
           Prescribed by Dr. (name/phone)________________________________________________________________________
     5.    Has physical condition which limits participation in classroom activities  Physical Education 
           If checked, please explain ____________________________________________________________________________

           Presently under care of doctor (name/phone)________________________________________________________________

								
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