First Grade/Second Grade Information Sheet

WOODRUFF PRIMARY SCHOOL FIRST GRADE/SECOND GRADE INFORMATION SHEET

SCHOOL USE ONLY Documents on File: ______Birth Certificate ______Certificate of Immunization ______Social Security Card Date Issued ______Proof of Residency ______Medical Exemption Until: ______SC Immunization School Official Signature: ______School Nurse Signature ______

STUDENT INFORMATION

FULL NAME: ______GRADE: _____ 1st ____ 2nd

NAME CALLED: ______SEX: _____ Male ______Female

SOC. SEC. #:______BIRTH CERT. #: ______BIRTH DATE: ______PLACE OF BIRTH: ______BIRTH WT: ______Mo/Day/Yr

ARE YOU HISPANIC OR LATINO? ______YES ______NO

WHAT IS YOUR RACE? _____ African American_____ American Indian or Alaska Native ____ Asian _____ Hawaiian Or Pacific Islander _____ White

ADDRESS: ______P.O. BOX(If Applicable): ______(City) ______(State) ____ Zip: ______

MOTHER/STEPMOTHER/GUARDIAN (WITH WHOM CHILD LIVES): NAME: ______AGE: _____ HOME PHONE:______PLACE OF EMPLOYMENT: ______WORK PHONE: ______

EDUCATIONAL LEVEL OF MOTHER/STEPMOTHER/GUARDIAN: (check one) ___ Less Than 9th Grade ___ Less Than High School ___ GED ___ High School Graduate ___ Technical School Graduate ___ College Graduate

FATHER/STEPFATHER/GUARDIAN (WITH WHOM CHILD LIVES): NAME: ______AGE: ____HOME PHONE:______PLACE OF EMPLOYMENT: ______WORK PHONE: ______

EDUCATIONAL LEVEL OF FATHER/STEPFATHER/GUARDIAN: (check one) ___ Less Than 9th Grade ___ Less Than High School ___ GED ___ High School Graduate ___ Technical School Graduate ___ College Graduate

KINDERGARTEN ATTENDANCE: FULL DAY ______HALF DAY ______NAME OF SCHOOL/PROGRAM: ______

Student Info. Sheet – revised – 05/14/2013 AC STUDENT HEALTH: (Does the child have a health problem that will impact regular attendance in school?)

YES _____ NO ______If yes, please describe: ______

OTHER SPECIAL HEALTH CONDITIONS (Allergies to foods, reactions to bee stings, etc.)

YES ____ NO _____ If yes, please describe: ______

MEDICAL CARE PROVIDER: (List the source the family generally uses for their medical care) FAMILY PHYSICIAN: ______DENTIST: ______EMERGENCY ROOM: ______CLINIC: ______OTHER:______

IF PARENTS CANNOT BE REACHED IN CASE OF EMERGENCY OR ILLNESS, PLEASE NOTIFY: NAME RELATIONSHIP TELEPHONE # 1. ______2. ______3. ______

LIST ALL OTHER CHILDREN IN FAMILY: SEX AGE GRADE SCHOOL ATTENDING 1. ______2. ______3. ______4. ______

METHOD OF TRANSPORTATION: (How child will be transported) ______BUS ______CAR ______NURSERY VAN

GIVE DIRECTIONS TO HOME: This information is only necessary if you live outside the Woodruff City limits. ______My child and I are legal residents of Spartanburg District Four.

PROOF OF RESIDENCY: Tax Receipt _____ Lease/Rental Agreement In Parent/Guardian’s Home ______

I attest that all information provided on this form is true and accurate.

Student Info. Sheet – revised – 05/14/2013 AC ______

Parent/Guardian Signature Signature Of School Official

______

Student Info. Sheet – revised – 05/14/2013 AC