<p> Student Information</p><p>Demographic Information</p><p>Student’s Legal Name ______Race/Ethnicity: First Middle Last Is the student Hispanic/Latino? Address:______Yes No</p><p>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 </p><p>Name of School: ______Grade: ______</p><p>Physical Address: NUMBER STREET </p><p>CITY STATE ZIP Phone Number: ______I give permission to request all records from this school.</p><p>Have you been in a Anderson County School before? Yes No </p><p>Which school and when? ______</p><p>If not, have you been in a Kentucky school before? Yes No </p><p>Which district and when? ______</p><p>Transportation</p><p>Does this student ride a bus? Yes No</p><p>If YES: Both ways Only TO school Only FROM school </p><p>____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</p><p>Address child gets ON bus:______Bus #______Address child gets OFF bus:______Bus #______</p><p>If school is DISMISSED EARLY for any reason (weather, etc.) my child will go home as usual, unless specified below:</p><p>Student Information Page 1 of 2 Last Updated: 4/4/2018 School Safety Information</p><p>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:</p><p> 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</p><p>The facts are as follows: ______</p><p>______</p><p>Participation in Programs</p><p>Please check any special programs in which the student has participated:</p><p>Speech/Language Special Reading IEP 504 Plan </p><p>Gifted/Talented Free/Reduced Lunch Extended School Services</p><p>Legal Issues</p><p>Other Issues or Concerns (Allergies, etc.) ______</p><p>For initial entry into Anderson County Schools (first time enrollees only):</p><p>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) </p><p>Student Information Page 3 of 2 Last Updated: 4/4/2018</p>