Iberia R-V Elementary Enrollment Form
It is a requirement that we have the following information on file at Iberia R-V School.  
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Student's Full Legal Name *
Name Used
Race *
Birthdate *
MM
/
DD
/
YYYY
S.S. # *
Grade this year
Is the student in foster care?
Clear selection
Previous School attended
Student's Mailing address
Student's Home Phone # 573
Father's Full Name
Father's Address
Dad's Work #
Dad's Home #
Dad's Call #
Mother's Full Name
Mother's Address
Mom's Work #
Mom's Home #
Mom's Cell #
Step Parent(s)/Guardian(s) Name(s)
Guardian's Address
Guardian's Home #
Guardian's Work #
Guardian's Cell #
Parent(s)/Guardian(s) with whom child resides with
Authorization to pick child up from school and emergency contact other then parent. Emergency Contact #1/Phone #:
Authorization to pick child up from school and emergency contact other then parent. Emergency Contact #2/Phone #:
Authorization to pick child up from school and emergency contact other then parent. Emergency Contact #3/Phone #:
Authorization to pick child up from school and emergency contact other then parent. Emergency Contact #4/Phone #:
Directions for Bus Driver : Directions to Home
Directions for Bus Driver : Directions to Other Bus Stop
Other Household Members/Relationship/Age
Special circumstances (Allergies, Asthma, Diabetes, Custody, etc.)
Family Doctor/Phone Number
Family Dentist/Phone Number
Hospital Preference
I request that you give Non-Aspirin pain reviler (Tylenol) or generic substitutes to my child during the school year in accordance with board policy.  See medications in handbook.  I authorize the school nurse or designee to give my child medication.  I will not hold the school staff responsible for any undesired reaction that may occur from the medication.  Please type your name below to agree.
I hereby affirm that my enrolling child Has or Has Not been expelled or suspended from any previous school
I hereby affirm that enrolling child is a resident of Iberia R-V School District under penalty of the Safe Schools Act. Please type your name below to agree
I give permission to publicize my child's picture, work or name on the district web page, facebook, and or newspaper.  Please type your name below to agree
Military Family Status
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Race/Ethnicity/Language
Is the first language of the student English?
Clear selection
Is a language other than English used in the home?
Clear selection
Are you Hispanic/Latino?
Clear selection
Please select one or more races from the following five racial groups:
Homeless Enrollment: Are you sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason?
Clear selection
Are you currently residing at a motel, hotel, in a car, or at a campsite because your home has been damaged or because of economic reasons?
Clear selection
Are you currently residing in a shelter?
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Are you currently living in a temporary housing arrangement due to economic hardship?
Clear selection
Migrant: Has either the parent, the guardian, or the child been employed (or is currently employed) within the past three years as a migratory working in some form of temporary employment or seasonal agricultural or agricultural-related work?
Clear selection
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