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Elmore City-Pernell Student Information 2022-2023
Enrollment Form
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* Indicates required question
Email
*
Your email
Legal Student Name (First, Middle, Last)
*
Your answer
Date:
*
MM
/
DD
/
YYYY
Grade of student
*
Pre-Kindergarten
Kindergarten
First
Second
Third
Fourth
Fifth
Other:
Last School Attended by Student
*
Your answer
Gender of Student
*
Female
Male
Other:
Residence Address:
*
Your answer
Mailing Address:
*
Your answer
Date of Birth:
*
MM
/
DD
/
YYYY
Place of Birth City
*
Your answer
Race:
*
Black
American Indian
Asian
Pacific Islander
White/Caucasian
Hispanic
Other:
Does your student have a Tribal Citizen Card or documentation? Present a copy to the office for your child to qualify for the JOM Program.
*
Yes
No
Please check the following programs in which your student has been a participant.
*
Childcare Program licensed by DHS
Sooner Start Program
Oklahoma Parents as Teachers Program
Children First Program
Child abuse prevention operated by State Department of Health
None
Other:
Required
Mother's Name (First & Last Name)
*
Your answer
Mother's e-mail address
Your answer
Mother's Employer
Your answer
Mother's Phone Number - must be a working number (no dashes)
*
Your answer
Mother's Business Phone Number (no dashes)
Your answer
Mother's Alternate Phone Number (no dashes)
Your answer
Father's Name (First & Last Name):
*
Your answer
Father's e-mail address
Your answer
Father's Employer
Your answer
Father's Phone Number - must be a working number (no dashes)
*
Your answer
Father's Business Number (no dashes)
Your answer
Father's Alternative Number (no dashes)
Your answer
Emergency Contact #1 (not the parent or guardian) & Relationship to student
*
Your answer
Emergency Contact #1 Phone Number (no dashes)
*
Your answer
Emergency Contact #2 (not the parent or guardian) & Relationship to student
*
Your answer
Emergency Contact #2 Phone Number (no dashes)
*
Your answer
Emergency Contact #3 (not the parent or guardian)& Relationship to student
*
Your answer
Emergency Contact #3 Phone Number (no dashes)
*
Your answer
Emergency Contact #4 (not the parent or guardian) & Relationship to student
*
Your answer
Emergency Contact #4 Phone Number (no dashes)
*
Your answer
Please select which person you want to be contacted in case of bad weather or other school notices sent out via text messages. Only one selection is allowed.
*
Mother's Cell phone
Father's Cell phone
Required
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