EFTA01246249.pdf

THE SCHOOL DISTRICT OF PALM BEACH COUNTY (SDPBC) New and Returning Student Registration NEW STUDENTS: Complete all non-shaded areas 011 both sides of the form. RETURNING STUDENTS: Review botlisides. If the pre-printed information is 'nconect, correct the Information by carefully and lightly crossing out the Incorrect Information and writing the correct information above It. (3) (4) (7) seem sECuerry NO. (0) NOME TELEPHONE NO (9)SEX POI FEAWETHNIE MON IFPFGAIN askan Native 0 E lacic. Non-Hispanic 0 H-Hispanic der etWhite, 5f Non.HIsparde 0 M-Muldracial OM mow STATUS (14) USA array DATE 0 O. Foreign Exchange Student pmecovren 01. Out-of-county Resident 0 2. Out-of-state Resident 04. In-county Resident YES NO (iti)eRISCH001.MOUND° iNfoRuAnoei LI 0 A. The student resides on federal property. Pigtail Xby eachprogram attendee Also. Indicate with 0 0 B. The student resides in low rent houskrg. at asterisk C) thegogreen your MO was in the lode!. Di 0 c. The parent le employed on federal property leaded in Palm Bead) Catty. 0 N. Non-subsidized Child Care 0 M. Migrant Pre-K 0 0 D. The parent is employed on low rent housing located in Palm Beach County 0 D. Pre-K Disabilities . El H. Headstart 0 0 E. The parent is in the uniformed services of United States. 0 t. PreK Early Intervention 0 C. Chapter I 0 S. Substdaed ChId Care 0 O. other. O 0 If E. Is YES, is the meant on active duty? Check service below: • • (Intialle STUDENT A 00)CURRENT GRADE LEVEL Mae 0 Air Force U Army 0 Coast Guard 0 Marries 0 National Guard 0 Navy O 0 YESIW 8 frir sy ( h9) tome OF Snort. TRANSFERRING 'ROW 120 OTY OR LOCATE:el all/AST A 4.)M4CE On7E PiOniee t / I ll b ede 54 #3° Z• Cps" pelt, r 1 et 6 ..) 6 6 i ne4. talLAST GRADE LEVEL PILAW PUBUC SCHOOL ATTENDED ,i4 PALM BEACH001AM WIDATE Annaba IN Mac MESVOStni(i gs) Students will receive non-invasive health screenings pursuant to Florida Statute § 381.0056{7)(d). Noninvasive it . screerings may include vision, hearing. scrims's, height, arid weight. These tests May be given individually or in i 12) Have an groups. Parents or guardans, however, have the right to request an exemption In writing. If you DO NOT want rep 4 oj rr free and your chord to receive the-screenings, write the words 'Do not weed' here: ducedd lunch? (This exemption wit cover all types of screenings) OYES RiTC cm I give permission for my child to participate in the sodium flouride program to prevent tooth decallg4S0 NO (Application is pibv,decl (Permission is valid through 6 grade) wilts this ban) !tat NOME LANGE:AGE Waver YES m....„.),*-- NO o j Is a language othfc than English used in the home? If YES, what language? 0 ec ' . 2. Does Me student have a first language other than English? II YES, what language? U el. "-Does the student most frequently speak a Language other than English? If YES, what language? (29) 4. What language is spoken in the home by the parent or guerilla/1? ..0O/.54 (30) 5. What language Is the student's first language? rniii‘ri/S4 (72)Myr INESWITIC —and' ni) What is the date of entry Into an ESOL program? tr filother 0 Father 0 Both Parents (33)CesCLOSuliEs Pa&MYINTOPee SCHOOL DtSTRICT 2( )ltior oilziot-bPsikeors YES NO, (SO CIATOOY STATUS Of SluDIEFIT peek** 0 _A. Has the student ever been expelled from school? 0 .M ).. Has the student ever had an arrest restAting Ina charge? 0 Mother 0 Father PShared Custody CI w?. Has the student ever had any juvenile justice actions? 0 Other PM le there a court order leaning either parent from removing or contacting the student during the school del? DYES. provide the school with a copy of the court order. RS.500636 (REV. 4162001) page 1 402 MM08-A HALL-000008 3501.103-025 CONFIDENTIAL Page 1 of 2 EFTA_00063113 EFTA01246249 THE SCHOOL DISTRICT OF PALM BEACH COUNTY • NEW AND RETURNING STUDENT REGISTRATION poMINER OR LEW& GUAROWI 0591. Sloe PISA PIO AO0FtESS (andir aanM. ant pwmanrnunte, CITY STATE 20/ COOS , OCCUPATCH . . . PUCE 00 EMPLOYIAEN NOME TRUMP* BLISNESS TELEPHONE CELUPAGER NUPOER EMAIL ADORESS profewI "WeTilleVitisakliA6 tram - F`'' 9...aarVagii ' aaM v inciiiit#:‘: sa Person(s) other than parent authorized to pick up student (PS) PASSWORD (P'T.2 Mc/Waders) (39) NAPE (t21 I>Nt WO 40 NAME (tit. aJ.V.in4lt ANS I (Mon . Sr.. UN( Abetlinealbabf4 STATE ZIP COOS •. I RIBA 1 (42)AUNORG!E0 FOR dI • I 0 YES 0 NO (44) ICDCAL INFORMATON alsiption Mona tfliGr. talk (0) II school parsOnnel are unable to contact you incase of Plness or accident, . H•' . . „rnhies swain. intdadrescntaleroteekerfrisatIree may we have your permission to call your doctor-dr. _ emergency seivices (9 1) for transportto the teseitan efii 0 NO (46)FAWLY PHYSICIAN (46)PHYSCAN RHONE on Does your rummy child have ht. nmedda, isv health Insurance? BIES 0 NO EYES. indicate: 47) HOSMT AL PREFERENCE 0 Medicaid likgate o Healthy Kids/Kid Care 0 Interested ki receiving information , .ITMailpi riilijal!r- i a: .. ".' ite (It NAME OF CHILD gut fat med. 1400 501004. ATTENDIVG CMOS BIRTH 00) NAME OF CIAO (Pst test med.M40 SCHOOL ATTEMINO DATE OF BRIM (SI) NOW OF MILO (kIt oat 49no P490 50400. AT1134DINO SWUMNO. foOkNQ WIN:* DATE Of BIRTH : '... (SOMME OFCHILD east Fat. °Akio MOO SCHOCC. ATTENC*90 STUDENT NO. Rollos* WADE DATEWORN PARENT/GUARDIAN SIGNATURE .... . . 0.0,10VV. .... -.7.. stiii4o_Ta *NUE ;?*" - r' c.3,/ I verify that the information given "qts'-c-" -Wiehr - is true and accurate to the best of :2, ,....t, ? ,.., .-- my knowledge. - .:••• . 0" ' , • ;I. .-. c —,-- - P • ., .. ::. • . • .. • -7. ,,,, . • . • .;•,c.1: - 2,•:". ---•;•••?:- -A,. nnen (tale Ion, A ICPM!ill CONFIDENTIAL Page 2 of 2 EFTA_00063114 EFTA01246250