For Initial Entry Into Anderson County Schools (First Time Enrollees Only)

Student Information

Demographic Information

Student’s Legal Name ______Race/Ethnicity: First Middle Last Is the student Hispanic/Latino? Address:______Yes No

Home Phone:______Cell Phone: ______Is the student from one or more of these races? Birth date: _____/______/______Place of Birth: ______GRADE: ______□ American Indian or Month Day Year Alaskan Native □ Asian Sex: Male  Female □ Black or African American Social Security # (not required)______□ Native Hawaiian or Other Pacific Islander Student Email Address:______□ White Last School Attended

Name of School: ______Grade: ______

Physical Address: NUMBER STREET

CITY STATE ZIP Phone Number: ______I give permission to request all records from this school.

Have you been in a Anderson County School before? Yes No

Which school and when? ______

If not, have you been in a Kentucky school before? Yes No

Which district and when? ______

Transportation

Does this student ride a bus? Yes No

If YES: Both ways Only TO school Only FROM school

____My child will NOT be transported by school bus. I will provide transportation. ____My child WILL ride the school bus. □ Over one mile from school □ Under one mile from school

Address child gets ON bus:______Bus #______Address child gets OFF bus:______Bus #______

If school is DISMISSED EARLY for any reason (weather, etc.) my child will go home as usual, unless specified below:

Student Information Page 1 of 2 Last Updated: 4/4/2018 School Safety Information

KRS 158.155 requires that a parent or guardian of a child who has been adjudicated guilty or previously expelled for homicide, assault, or violation of state law or school regulations relating to weapons, alcohol or drugs notify a new school of that fact by a sworn statement given to the school at the time of registration. In compliance with this requirement, please check any of the following that apply to this student:

adjudicated guilty expelled from school (If applicable, please list the name of the school:______) disciplined for a violation of state law or school regulation relating to weapons, alcohol, or drugs

The facts are as follows: ______

______

Participation in Programs

Please check any special programs in which the student has participated:

Speech/Language Special Reading IEP 504 Plan

Gifted/Talented Free/Reduced Lunch Extended School Services

Legal Issues

Other Issues or Concerns (Allergies, etc.) ______

For initial entry into Anderson County Schools (first time enrollees only):

I have supplied a Kentucky Eye Exam by an ophthalmologist or optometrist (For initial entry into a Kentucky School only) I have supplied a Certified Birth Certificate; or Other Reliable Proof of the student’s identity and age, and/or an Affidavit of the inability to produce a copy of the birth certificate. I have supplied a Kentucky Immunization Certificate. I have supplied a copy of a recent Health Physical Examination. Student Information Page 2 of 2 Last Updated: 4/4/2018 I have supplied a copy of a recent Dental Exam. I have completed a Free/Reduced Lunch Application. (Optional)

Student Information Page 3 of 2 Last Updated: 4/4/2018