2021-2022 Two Rivers New Student Enrollment Form

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Email *

Student Name (Please Include Middle Name) *

Student Birthdate *

YYYY

Gender *

Female

Male

Student Grade for 2021-2022 School Year *

Pre School

Kindergarten

1st Grade

2nd Grade

3rd Grade

4th Grade

5th Grade

6th Grade

7th Grade

8th Grade

9th Grade

10th Grade

11th Grade

12th Grade

Medicaid Number

Social Security Number *

Last School Attended (Please include city and state) *

Is your child currently under expulsion/expulsion proceeding from another district? *

Yes

Has your child ever been retained? *

Yes

If your child has been retained, what grade?

Did your child attend a pre-school prior to Kindergarten?

Yes

Clear selection

If yes, please give the name of the pre-school attended.

High School Only:

Smart Core

Core

Clear selection

Do you have internet access? *

Yes

Is the student Hispanic or Latino? *

No, not Hispanic or Latino

Yes, Hispanic or Latino (A person of Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture or origin, regardless of race.)

What is the student's race? (Regardless of how respondent answered the first question, choose one or more) *

American Indian or Alaska Native (A person having origins in any of the original peoples of North and South America, including Central America, and who maintains tribal affiliation or community attachment)

Asian (A person having origins in any of the original peoples of the far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan the Philippine Islands, Thailand, and Vietnam.)

Black or African American (A person having origins in any of the black racial groups or Africa)

Native Hawaiian or other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, and other Pacific Islands.)

White (A person having originals in any of the original peoples of Europe, the Middle East, or North Africa.)

Required

Home Language: (If not English) *

Curriculum: *

Regular

Special Ed.

Gifted and Talented

Has your child ever been identified as any of the following? Please check all that apply

504

E.S.L.

Migrant

Meal Status:

Free

Reduced

Paid

Clear selection

How far do you live from school?

Will your child ride a bus? *

Yes

Who does this student live with? *

Both Parents

Mother Only

Father Only

Mother/Stepfather

Father/Stepmother

Grandparent(s)

Legal Guardian

Spouse

Other

Required

If "Other", please explain

1st Parent/Guardian Name *

1st Parent/Guardian Relation to student *

Mother

Father

Stepmother

Stepfather

Grandmother

Grandfather

Aunt

Uncle

Sibling

Legal Guardian

1st Parent/Guardian Cell Phone Number (with area code, please) *

1st Parent/Guardian Home Phone Number (with area code, please) *

1st Parent/Guardian Work Phone Number (with area code, please) *

1st Parent/Guardian Place of Employment *

1st Parent/Guardian E-mail Address *

2nd Parent/Guardian Name *

2nd Parent/Guardian Relation to student *

Mother

Father

Stepmother

Stepfather

Grandmother

Grandfather

Aunt

Uncle

Sibling

Legal Guardian

2nd Parent/Guardian Cell Phone Number (with area code, please) *

2nd Parent/Guardian Home Phone Number (with area code, please) *

2nd Parent/Guardian Work Phone Number (with area code, please) *

2nd Parent/Guardian Place of Employment *

2nd Parent/Guardian E-mail Address

Other Persons Living in the Home (please include siblings) *

1st Emergency Contact Name *

1st Emergency Contact Phone Number *

What is this contact's relationship to the student? *

2nd Emergency Contact Name *

2nd Emergency Contact Phone Number *

What is this contact's relationship to the student? *

Student's Physical/911 Address (Please include city and zip code) *

Student's Mailing Address (Please include city and zip code) *

Phone number or the school messenger system that notifies for special events, weather closings etc, This system will leave a message.

Would you like a Home Access Center (HAC) account set up to view your child's grades online (only applicable in Grades 3-12) *

Yes

Family Doctor (Please include location and phone number)

Preferred Hospital

Please provide us with any medical information or other history about your child that may be important to our work with him or her. Has he or she had any serious illness or injury that will affect his or her school work?

Please list any allergies your child may have.

Does your child require any medication to be dispensed during school hours? *

Yes

If yes, please list:

Please list any other situations/circumstances the school should be aware of in order to best work with your child.

The following information is optional. It is used only to determine if your child is eligible for assistance with immediate needs. Please check those that apply.

Sharing housing of others due to loss of housing, economic hardship, or similar reasons

Highly mobile resulting in lack of school stability and educational continuity

Living in a motel, hotel, travel trailer part, campground, or vehicle due to lack of alternative acommodations

Living in emergency or transitional shelters (including foster care)

Living in public or privalte place not designed for humans to live.

Designated migratory children living in above circumstances

By checking this box and typing my name below, I am electronically signing this enrollment form as this student's parent or legal guardian *

I agree

Required

First Name *

Middle Name *

Last Name *

Submit

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