PLEASE COMPLETE AND PRINT CLEARLY THE STUDENT INFORMATION FORM

							GIBRALTAR SCHOOL DISTRICT REGISTRATION FORM

                                                                                                                                       /             /
BUILDING NAME                                             TEACHER NAME                                        COUNSELOR#      ENTRY DATE: MM/DD/YY
(This section to be completed by office.)



PLEASE COMPLETE AND PRINT CLEARLY

STUDENT INFORMATION



STUDENT’S LAST NAME                                                             FIRST NAME                                          MIDDLE NAME


               -            -                                 /            /
SOCIAL SECURITY NUMBER                               BIRTH DATE: MM/DD/YY                           SEX: M or F      YEAR OF GRADUATION


      ETHNICITY: 1=CAUCASIAN 2=AFRICAN AMERICAN 3=HISPANIC
      4=ASIAN 5=AMERICAN INDIAN 6=OTHER PACIFIC ISLANDER
                                                                  LANGUAGE SPOKEN AT HOME                                           GRADE

STUDENT ADDRESS INFORMATION



STREET NUMBER               STREET NAME




CITY                                                                             ZIP CODE             APT#


               -                 -                        1=LISTED
                                                          2=UNLISTED
AREA CODE          HOME PHONE


MAILING ADDRESS:
                           PO BOX, Apt #, Lot #        CITY                                                                         STATE          ZIP


STUDENT BIRTH INFORMATION

                                                                                                    Y=YES
                                                                                                    N-NO

CITY OF BIRTH                                                                      STATE        US CITIZEN?

PARENTS/GUARDIANS


1.
     LAST NAME                                                                     FIRST NAME                                         RELATIONSHIP

E-mail Address (Please print):


                   -                 -                                -                    -                                -                -
AREA CODE              HOME PHONE                         AREA CODE            WORK PHONE                         AREA CODE       CELL PHONE


2.
     LAST NAME                                                                     FIRST NAME                                           RELATIONSHIP

E-mail Address (Please print):


                   -                 -                                -                    -                                -                -
AREA CODE              HOME PHONE                         AREA CODE            WORK PHONE                         AREA CODE       CELL PHONE

Address if parent is living elsewhere: (Please include PO Box, Apt #, Lot #)


 HOME ADDRESS
                          STREET NUMBER           STREET NAME




CITY                                                                             ZIP CODE             APT#
EMERGENCY INFORMATION, other than parent or guardian


1.
     EMERGENCY CONTACT LAST NAME                                    FIRST NAME                                          RELATIONSHIP


             -            -                               -                -                               -                 -
AREA CODE        HOME PHONE                    AREA CODE       WORK PHONE                        AREA CODE       CELL PHONE


2.
     EMERGENCY CONTACT LAST NAME                                   FIRST NAME                                           RELATIONSHIP


             -            -                               -                -                               -                 -
AREA CODE        HOME PHONE                    AREA CODE       WORK PHONE                        AREA CODE       CELL PHONE


3.
     EMERGENCY CONTACT LAST NAME                                   FIRST NAME                                           RELATIONSHIP


             -            -                               -                -                               -                 -
AREA CODE        HOME PHONE                   AREA CODE        WORK PHONE                        AREA CODE       CELL PHONE


     If custody of your child is a concern, provide a copy of the Personal Protection Order and/or Custody
     papers and complete the information below.
     LEGALLY, DO NOT RELEASE MY CHILD TO:

K-5 Early Dismissal: (6-12 optional)
In case of an UNSCHEDULED CLOSING, MY CHILD SHOULD GO TO THE ADDRESS BELOW. PLEASE BE SURE THAT YOUR CHILD
KNOWS WHERE TO GO.



EMERGENCY CONTACT LAST NAME                                      FIRST NAME                                        RELATIONSHIP


 HOME ADDRESS
                   STREET NUMBER       STREET NAME




CITY                                                              ZIP CODE            APT#


             -            -                               -                -                               -                 -
AREA CODE        HOME PHONE                    AREA CODE       WORK PHONE                        AREA CODE       CELL PHONE

     DOES YOU CHILD RECEIVE ANY SPECIAL SERVICES?                               Yes    No
     If YES, please attach current IEP.

STUDENT PREVIOUS INFORMATION



NAME OF SCHOOL DISTRICT LAST ATTENDED                                                                            L.E.A. CODE




NAME OF SCHOOL LAST ATTENDED




CITY OF LAST SCHOOL LOCATION                                           STATE OF LAST SCHOOL LOCATION


I affirm that all information provided on this form is true and accurate.

                                   SIGNATURE OF PARENT/GUARDIAN                                                  DATE


The following information either must have been seen or is attached. Birth Certificate, Immunization Records, Proof of Residency, Previous
Report Card, Copy of Transcripts.