<p> WOODRUFF PRIMARY SCHOOL FIRST GRADE/SECOND GRADE INFORMATION SHEET</p><p>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 ______</p><p>STUDENT INFORMATION</p><p>FULL NAME: ______GRADE: _____ 1st ____ 2nd </p><p>NAME CALLED: ______SEX: _____ Male ______Female </p><p>SOC. SEC. #:______BIRTH CERT. #: ______BIRTH DATE: ______PLACE OF BIRTH: ______BIRTH WT: ______Mo/Day/Yr </p><p>ARE YOU HISPANIC OR LATINO? ______YES ______NO</p><p>WHAT IS YOUR RACE? _____ African American_____ American Indian or Alaska Native ____ Asian _____ Hawaiian Or Pacific Islander _____ White</p><p>ADDRESS: ______P.O. BOX(If Applicable): ______(City) ______(State) ____ Zip: ______</p><p>MOTHER/STEPMOTHER/GUARDIAN (WITH WHOM CHILD LIVES): NAME: ______AGE: _____ HOME PHONE:______PLACE OF EMPLOYMENT: ______WORK PHONE: ______</p><p>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</p><p>FATHER/STEPFATHER/GUARDIAN (WITH WHOM CHILD LIVES): NAME: ______AGE: ____HOME PHONE:______PLACE OF EMPLOYMENT: ______WORK PHONE: ______</p><p>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</p><p>KINDERGARTEN ATTENDANCE: FULL DAY ______HALF DAY ______NAME OF SCHOOL/PROGRAM: ______</p><p>Student Info. Sheet – revised – 05/14/2013 AC STUDENT HEALTH: (Does the child have a health problem that will impact regular attendance in school?)</p><p>YES _____ NO ______If yes, please describe: ______</p><p>OTHER SPECIAL HEALTH CONDITIONS (Allergies to foods, reactions to bee stings, etc.) </p><p>YES ____ NO _____ If yes, please describe: ______</p><p>MEDICAL CARE PROVIDER: (List the source the family generally uses for their medical care) FAMILY PHYSICIAN: ______DENTIST: ______EMERGENCY ROOM: ______CLINIC: ______OTHER:______</p><p>IF PARENTS CANNOT BE REACHED IN CASE OF EMERGENCY OR ILLNESS, PLEASE NOTIFY: NAME RELATIONSHIP TELEPHONE # 1. ______2. ______3. ______</p><p>LIST ALL OTHER CHILDREN IN FAMILY: SEX AGE GRADE SCHOOL ATTENDING 1. ______2. ______3. ______4. ______</p><p>METHOD OF TRANSPORTATION: (How child will be transported) ______BUS ______CAR ______NURSERY VAN</p><p>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.</p><p>PROOF OF RESIDENCY: Tax Receipt _____ Lease/Rental Agreement In Parent/Guardian’s Home ______</p><p>I attest that all information provided on this form is true and accurate.</p><p>Student Info. Sheet – revised – 05/14/2013 AC ______</p><p>Parent/Guardian Signature Signature Of School Official</p><p>______</p><p>Date</p><p>Student Info. Sheet – revised – 05/14/2013 AC</p>