Uintah School District

UINTAH SCHOOL DISTRICT For Office Use Only STUDENT INFORMATION-REGISTRATION FORM Student Number - Please Print - Entry Date From The information you provide is helpful and necessary. Strict standards of confidentiality will be observed Exit Date To

Today’s Date Enrolling in Grade Gender M or F Student’s Legal Name M or F Birth Date Last First Full Middle Month Day Year Day Phone Street Address Mailing Address Home Phone City State Zip Place of Birth Name of Last School Attended ______Address of Last School Attended ______Has this student ever attended school in Uintah School District before? Yes No

Has this student ever attended another school in Utah before? Yes No

Student lives with (check one) Parents Mother Father Other (specify)

Father’s Name Mother’s Name If guardian is different than parent listed above please If guardian is different than parent listed above please give name below. give name below Guardian’s Name Guardian’s Name Give the following information for parent or Give the following information for parent or guardian. guardian. Relationship to Student Relationship to Student Employer Employer Work Phone Work Phone Cell Phone Cell Phone Email Address Email Address Check here to indicate sole custody of child (Copy of legal Check here to indicate sole custody of child (Copy of custody document must be in student’s file) legal custody document must be in student’s file)

EMERGENCY CONTACT AND CHECK OUT INFORMATION Only legal guardians or those named on this document will be allowed to check this student out of school. These individuals will be contacted in case of an emergency IF a parent/guardian cannot be reached. As the parent/legal guardian of the above named student, I give permission for the following individuals(s) to check my child out of school if needed. Name Relationship Phone Name Relationship Phone Name Relationship Phone PARENT/GUARDIAN SIGNATURE

Special Programs Which, if any, of the following special programs was the student enrolled in at the previous school? (Check all that apply) Alternative Language Services Special Education(Resource) with IEP Speech Other

Ethnicity: Is the student (or are you) Hispanic/Latino? (check only one) No Yes (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.)

Please note that this question is about ethnicity, not race. No matter what you select for ethnicity, please answer the following question about your student’s (or your) race also. Race: What is the student’s (or your) race? (check one or more): American Indian/Alaska Native (A person having origins in any of the original peoples of North and South American, including Central America, and who maintains tribal affiliation or community attachment.) Tribal Affiliation if Indian: Goshute Navajo Paiute Northwest Band Shoshone Ute Other Asian (A Person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.) Black/African American (A person having origins in any of the black racial groups of Africa.) Native Hawaiian/Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.) White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.)

Health Concerns:

Does your student have health concerns? Yes or No

Has student been suspended or expelled from school because of a safe school violation?  Yes No If yes, please explain (Misrepresentation may be cause for expulsion) ______

Revised 6/11/2015