Hector School District

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Student Registration Form

Student Name (First, Middle, Last) *

Student Date of Birth *

YYYY

Grade *

Last School Attended

Address of Last School Attended

Travel to/from school (please check one) *

Bus

Drives Self

Parent/guardian

Walk/Bike

Please list individuals who may pick up your students.

Student's Gender *

Male

Female

Social Security Number *

Race *

Home Language *

Please choose which of the following situations the student currently resides in (You can choose more than one.) *

House or apartment with parent or guardian

Motel, car or campsite

Shelter or other temporary housing

With friends or family members (other than or in addition to parent/guardian)

Required

Parent/Guardian Information

Name *

Relationship to Student *

Physical Address *

Mailing Address (if different from above)

Email Address *

Home Phone *

Cell Phone *

Work Phone *

Medical Alerts

If your child has a serious medical condition please discuss this with the school nurse, Mrs. Cheryl Nielsen at (479) 284-2213 prior to attending school so that conditions that require accommodations while the student is at school may be made prior to student attending classes. Physician orders/documentation may be required.

Cause of Allergy #1

Treatment of Allergy #1

Option 1

Clear selection

Cause of Allergy #2

Treatment of Allergy #2

Medical History- Check all that apply *

None

ADD/ADHD

Anxiety/Panic Attack

Asthma

Bee Sting Allergy

Bowel Disorder

Cerebal Palsy

Color Blindness

Diabetes

Epi-pen usage

Food Allergy

Headaches

Hearing Disorder

Heart Condition

Bladder Disorder

Muscle Disorder

Orthopedic Disorder

Seizure Disorder

Vision Disorder

Required

Medication

For any medication to be given at school, parent/guardian must bring medication to the nurse's office and complete appropriate consents. All over the counter medication will require a physician's order before it can be given to the student at school. This inlcudes Tylenol, Ibuprofen, and Benadryl. Medications must be in original containers from pharmacy. Student's name, specific directions including times to be given must be listed on label from the pharmacy.

Please list all prescription, over the counter and herbal medication including the name, reason given, and time medication is given. *

Does student have a medicaid card? *

Yes

Please list the medicaid card #.

Authorization for ambulance and/or other emergency services: *

Yes

Required

Family Doctor

Family Doctor Phone #

Have you ever been expelled from any school or under expulsion proceedings? *

Yes

If Yes, give name of school and dates of expulsion.

Acknowledgment

- I acknowledge that I understand that any student who violates the student discipline policies shall be subject to disciplinary action. I also understand and agree thatmy child(ren) shall be held accountable for their behavior and consequences outlined in the student handbook at school, at school sponsored travel/activities, and for any school related misconduct, regardless of time or location. I acknowledge that I have received my copy of this statement from Superintendent Mark Taylor with information regarding the student discipline.

- Parents and students are hereby informed that the student handbook(s) are online and that they contain the Hector School District Discipline Policies. If a written copy is requested, please notify the High School office.

- I have received a copy of the rules in the 2022-2023 student handbook and have discussed them with my child to provide safety for all students to and from school.

- I understand and acknowledge that Hector School District Does not discriminate on the basis or race, religion, color, national origin, sex, or handicap in providing educational services. Mrs. Brenda Pearce has been designated to coordinate compliance with the nondiscrimination requirements of Title IX and may be reached at (479) 284-3586. Mrs. Sara Turney has been designated to coordinate Section 504 of the Rehabilitation Act and may be reached at (479) 284-3536.

- I hereby consent to allow my/our student to take part in the Hector School District Chemical Screen Test Program. By doing so, the Hector School District is providing an opportunity to help students be drug free. The school solicits your support for your student by asking that you sign this form. By doing so, your child will be able to take part in extracurricular activities which include: class trips, dances, homecoming festivities, choir/band activities, club activities after school, student elections, cheerleading, sports, quiz bowl, dance, prom decorating, prom committee, and al other activities not directly related to the academic day. Failure to sign and return this form will exclude your student from taking part in these activities.
School nurse may contact physician/physicians for any medical purposes for my child for discussion/questions pertaining to treatment given by the school nurse.

I acknowledge that I have read the above statement. *

I consent to my student being photographed or filmed in relation to instructional programs and/or other school related activities, and their names may be listed publicly in relation to such programs or activities. The pictures, films, and/or names may be published in public newspapers, school newspapers, school yearbooks, slides, brochures, videos, CD's, and/or posted on the Hector School District website or other media. The following list includes situation or activities where students may be photographed, filmed, and/or have their names published: 1) Classroom Observations; 2) Academic Achievements; 3)Honor Roll Lists; 4) Athletic Activities; 5) Music Activities; 6) Contest Participation; 7) Program Participation; 8)Organization Participation: 9) Other Miscellaneous Events. *

I hereby GRANT permission for photograph(s), film(s), and/or the name of my student to be published publicly in relation to instructional and/or other events of the Hector School District.

I hereby DENY permission for photograph(s), film(s), and/or the name of my student to be published publicly in relations to instructional and/or other events of the Hector School District.

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