Rutledge Elementary School Enrollment Form

Date: ______Teacher: ______Grade: ______Bus: ______Social Security #: ______Birthday: ______Sex: M or F Student Name: ______Home Phone: ______(Circle One) Last First Middle Include Area Code Address: ______Street City Zip State of Birth: ______City of Birth: ______Country of Birth: ______Ethnic Status: (Circle One) American Indian, Alaskan Native, Hispanic, Black, White, Multi-Racial, Other:______Do you speak a Language other than English? (Circle One) Yes or No Language spoken at home: ______Is your child currently suspended, expelled, or zero tolerance from any school? (Circle One) Yes or No What type of school has your child attended? (Circle One)Regular Public, Private, Alternative, Homeschool, Other______Has your Child attended a Day or Residential treatment program? (Circle One) Yes or No Does your child currently have an IEP? (Circle One) Yes or No Has your child attended a Grainger County School before? (Circle One) Yes or No If yes what school? ______Where does your child stay at night? (Please Check One) ____Home/Apartment owned or rented by the parent(s)/guardian(s) ____With a relative or friend (family does not have a residence) ____In a shelter ____In a motel ____In an automobile ____A campsite ____In a housing that is inadequate (i.e. no electricity, running water, etc.)

Mother’s Name: ______Mother’s Maiden Name: ______Mother’s Work #: ______Emergency #: ______Father’s Name: ______Father’s Work #: ______Student resides with: (Check One) ____Both Parents, ____ Father, ____Mother, ____Guardian(s) Guardian’s Name (If applicable): ______RECORDS REQUEST

I hereby authorize the Grainger County School System to obtain the following information concerning the above named student:

___Standard Education Records Last School Attended ___Report Card ___Psychological Report Name: ______Special Education Placement Form (I.E.P.) ___Special Education Eligibility Form Address: ______Vision/Hearing Test ___Immunizations Certificate City: ______Birth Certificate ___Social Security Card State: ______Zip: ______

Send records to the following: PARENT SIGNATURE: ______Rutledge Elementary School 7480 Rutledge Pike Rutledge, TN 37861 or Fax: 865-828-5797 If You Have Questions Call: 865-828-5530