CANUTE ELEMENTARY K-6TH OFFICIAL ENROLLMENT FORM

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2021-2022

Email *

DATE *

YYYY

BUS NUMBER

GRADE *

Kindergarten

1st

2nd

3rd

4th

5th

6th

Student Shirt Size *

TEACHER

TRANSFER (OUT OF DISTRICT/STUDENT) OR RESIDENT (LIVES WITHIN SCHOOL DISTRICT/STUDENT) *

FULL NAME (FIRST, MIDDLE, LAST) *

GENDER: *

Female

Male

PLEASE TURN IN SOCIAL SECURITY NUMBER TO THE OFFICE IF REQUIRED! *

DATE OF BIRTH (MM/DD/YYYY) *

PLACE OF BIRTH (TOWN,STATE) *

SCHOOL LAST ATTENDED *

LOCATION OF SCHOOL LAST ATTENDED (TOWN,STATE) *

MOTHER'S NAME (FIRST, LAST) *

FATHER'S NAME (FIRST, LAST) *

MOTHER'S PHONE (XXX-XXX-XXXX) *

FATHER'S PHONE (XXX-XXX-XXXX) *

WORK (XXX-XXX-XXXX) *

RACE *

LANGUAGE OTHER THAN ENGLISH? *

YES

IF YOU SPEAK ANOTHER LANGUAGE OTHER THAN ENGLISH PLEASE INDICATE IT HERE.

PHYSICAL ADDRESS ( NUMBER + STREET NAME, IE. 100 E. MAIN - PO BOX 111) *

PHYSICAL ADDRESS (CITY) *

PHYSICAL ADDRESS (STATE) *

PHYSICAL ADDRESS (ZIP CODE) *

MAILING ADDRESS ( NUMBER + STREET NAME, IE. 100 E. MAIN - PO BOX 111) *

MAILING ADDRESS (CITY) *

MAILING ADDRESS (STATE) *

MAILING ADDRESS (ZIP CODE) *

SIBLINGS ENROLLED IN CANUTE PUBLIC SCHOOLS (NAMES / GRADES) *

EMERGENCY CONTACT #1 (NAME, RELATIONSHIP, PHONE #) *

EMERGENCY CONTACT #2 (NAME, RELATIONSHIP, PHONE #) *

EMERGENCY CONTACT #3 (NAME, RELATIONSHIP, PHONE #) *

WHO DOES THE STUDENT LIVE WITH? *

BOTH PARENTS

MOTHER

FATHER

GRANDPARENTS

MOTHER & STEPDAD

FATHER & STEPMOM

GRANDMOTHER

GRANDFATHER

AUNT & UNCLE

MOTHER & FRIEND

FATHER & FRIEND

MOTHER/FATHER 50/50

PRIMARY MOTHER/SHARED

PRIMARY FATHER/SHARED

AUNT

UNCLE

DHS

FOSTER PARENTS

MEDICAL INFORMATION / AUTHORIZATION TO ADMINISTER MEDICINE

ASTHMA *

Yes

Required

MEDICAL/FOOD ALLERGIES *

OTHER MEDICAL INFORMATION

AUTHORIZATION INFORMATION:

I, AS THE LEGAL PARENT/GUARDIAN OF THE ABOVE STUDENT, AUTHORIZE AN EMPLOYEE OF CANUTE PUBLIC SCHOOLS TO ADMINISTER A NON-PRESCRIPTION MEDICATION SUCH AS IBUPROFEN, PEPTO BISMOL, ETC. AND/OR A PRESCRIBED MEDICATION THAT I SEND TO SCHOOL ALONG WITH INSTRUCTIONS FOR ADMINISTRATION. I UNDERSTAND THAT UNDER STATE LAW, CANUTE PUBLIC SCHOOLS OR ITS REPRESENTATIVES SHALL NOT BE LIABLE TO THE STUDENT OR THE STUDENT'S PARENT/GUARDIANS FOR CIVIL DAMAGES FOR ANY PERSONAL INJURIES TO THE STUDENT WHICH RESULT FROM ACTS OR OMISSIONS OF SCHOOL EMPLOYEES IN ADMINISTERING THE MEDICATION I HAVE AUTHORIZED.

PARENT SIGNATURE FOR THE ABOVE QUESTION IN REGARDS TO MEDICATION (PLEASE TYPE YOUR FULL LEGAL NAME) *

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