Maple Public School

Maple Public School 2015-2016 Pre-K-8th ENROLLMENT FORM

Student’s Legal Name______Grade_____ Gender: M or F Last Name First Middle

Resident Address______Date of Birth______Street City State Zip

Mailing Address (if different from above) ______City Zip Primary Phone Number______

Place of Birth______SSN ______-______-______City State Country If student was not born in the USA: USA Entry Date:______First USA Enrollment Date:______

If your child was born in a country other than the USA, what date did he/she first enter the country?______

Ethnicity (circle all that apply):

African American Hispanic American Indian/Native Alaskan Asian Caucasian Pacific Islander

In addition to the selected ethnicity, is this student of Hispanic or Latino descent?  Yes  No

Student resides with: Both Parents  Mother  Father  Mother/Stepfather  Father/Stepmother  Legal Guardian

Student is living: (check only one) Rent/own my own home or apartment Temporarily with another family member or friend until In temporary foster care awaiting placement we can locate affordable housing  In a hotel or motel  In an emergency or transitional shelter With an adult that is not a parent or legal guardian  In a vehicle, park, campground, or on the streets Alone or in different location, without an adult serving as caregiver  In a house, building, or trailer WITHOUT running water/electricity Wherever I can find a place to stay at night Other, Please explain:______

Parents/Guardians: Name Relationship Place Employed Work Phone Cell Phone/Pager Email Address ______

______

Child’s Siblings: Name Relationship Age/Grade ______

Emergency Contacts: (In the event that we are unable to locate the parents/guardian, who can we call?) Name Relationship Home Phone Other Phone

______

Please list all parties authorized to pick up your child along with a phone number:

______

YES – NO Is the custody of this child decreed by the courts? If YES, who has primary custody? ______Relationship______Court documents declaring custody need to be in student’s school file

How does your child usually get home from school? (circle one) Car Bus #______

YES – NO Does your child live more than a mile and a half (1.5 miles) from the school he/she attends?

YES – NO Does your child use a name other than his/her legal name? If so what is it? ______

YES – NO Does your child reside in the Maple School district? If NO, what district do you live in and how did you hear about Maple School district? ______

YES – NO Did this student attend Maple Public School last year? If NO, list the name, address, and phone number where the student attended______

YES – NO Is either parent/guardian in the military or a civilian working on Federal property? If yes, who? ______where?______and fill out FORM B Eligible Government Properties: Federal Correctional Institution-FCI Concho Indian Agency Federal Transfer Center Lucky Star Tinker Air Force Base Indian Health Services Federal Highway Administration VA Medical Center Riverside Indian School Farming Indian Land U.S. Geological Survey FAA-Mike Mahoney U.S. Postal Service-OKC Office only (not El Reno Uniformed Services (Nat’l Guard, Army, Air Force, Marines, Navy, Reserves, etc.)

YES – NO Is the resident address owned by the Federal Correctional Institution, Concho Indian Housing Authority or located on Indian land or low income housing? If yes, fill out FORM B

Special Programs: Please circle all programs that your child has received:

Talented and Gifted Speech OT/PT Special Education Title VII/JOM 504 Plan IEP Other______

YES – NO Do you use a language other than English in your home (this includes Native American Indian Languages)? If yes, what language? ______and fill out Home Language Survey

YES – NO I give permission for my child to have access to the Internet.

YES – NO I give permission for my child’s picture to be used in school publications. (newspaper, websites, Facebook, etc.)

YES – NO I give permission for my child to participate in class fieldtrips. (information will be sent home before each trip)

YES – NO I give permission for my child to receive vision, hearing, and any other screening tests.

YES – NO I give permission for my address and phone number to be on the Maple School Patron & Student List.

YES – NO Has the child been issued a Medicaid number? If yes, give number ______

YES – NO Do you have any degree of American Indian ancestry or have a CIDB card? (if yes, fill out FORM C)

YES – NO Does this student take medication on a regular basis? If yes, list______

______

YES – NO Does this student have any health problems, including seasonal, drug, or food allergies? Explain: ______

______

YES – NO I give permission for my child to receive over-the-counter medications administered in the school office, as well as first aid care.

I, the undersigned, do hereby authorize officials of Maple Public School District to contact directly the persons named in this document, and do authorize the named physicians to render such treatment as may be deemed necessary in an emergency, for the health of said child.

In the event physicians, other persons named in this document, or parents cannot be contacted, the school officials are hereby authorized to take whatever action is deemed necessary in their judgment, for the health of the said child.

I will not hold the school district financially responsible for the emergency care and/or transportation for said child.

Doctor: 1st choice______Phone ______2nd choice______Phone ______

Hospital Choice: ______

Address: ______Phone ______Parent’s / Guardian’s Signature Date