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Eastside Elementary Kindergarten Registration
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* Indicates required question
Student First Name
*
Your answer
Student Middle Name
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Your answer
Student Last Name
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Your answer
Student Birthdate
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MM
/
DD
/
YYYY
Gender
*
Female
Male
Race
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White
Hispanic/Latino
American Indian or Alaska Native
Asian
African American
Native Hawaiian or other Pacific Islander
Student social security number
*
Your answer
Language spoken at home
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Your answer
Student physical address
*
Your answer
Student mailing address
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Your answer
Parent/Guardian 1 First and Last Name
*
Your answer
Parent/Guardian 1 Relationship to Student
*
Your answer
Parent/Guardian 1 Mailing Address
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Your answer
Parent/Guardian 1 Email address
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Your answer
Parent/Guardian 1 home and cell numbers (please specify which is home and which is cell)
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Your answer
Parent/Guardian 1 Alert Phone Number (this is the number used by school notification system)
*
Your answer
Parent/Guardian 1 Employer and work Phone number.
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Your answer
Does the student live with Parent/Guardian 1?
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Yes
No
Parent/Guardian 2 First and Last name.
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Your answer
Parent/Guardian 2 relationship to student.
*
Your answer
Parent/Guardian 2 mailing address.
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Your answer
Parent/Guardian 2 email address.
*
Your answer
Parent/Guardian 2 home and cell numbers (please specify which is home and which is cell)
*
Your answer
Parent/Guardian 2 Alert Phone Number (this is the number used by school notification system)
*
Your answer
Parent/Guardian 2 Employer and work Phone number.
*
Your answer
Does the student live with Parent/Guardian 2?
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Yes
No
Did your child have a 504 or receive special education services at a previous school?
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Yes
No
Please list the COUNTRY, CITY, and STATE where the child was born.
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Your answer
How will your child travel TO school?
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Bus
Car with parent or guardian
Other:
How will your child travel FROM school?
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Bus
Car with parent or guardian
Other:
Which preschool did your child attend?
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ABC (Arkansas Better Chance)
Even Start
Early Childhood
Headstart
21st Century Learning Center
Private Preschool
Public Preschool
Not Applicable
Other:
Student birth certificate number.
*
Your answer
Student resident county.
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Your answer
Is this child a dependent of an active or reserve member of a branch of the United States Armed Services?
*
Yes
No
If you answered YES to the last question, please select which branch of the US Armed Services.
Choose
Active Duty- US Army
Active Duty- US Coast Guard
Active Duty- US Air Force
Active Duty- US Navy
Active Duty -US Marines
Reserves- US Army
Reserves- US Coast Guard
Reserves- US Air Force
Reserves- US Marines
National Guard- US Army
National Guard- US Air Force
Parents Serve in Multiple Branches
Other
None
Is this student a twin, triplet, or another type of multiple?
*
Yes
No
Other:
If you would like to add another guardian contact please list their name, address, phone number, and relationship to student here.
Your answer
Student Emergency contacts. (contacts other than guardians to be called in case of any emergency)
*
Your answer
Please list physician name and phone number.
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Your answer
List any medical concerns or medications for student.
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Your answer
Please list last school attended, address, and phone number.
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Your answer
Has this child been expelled from school in any other district or is the child a party to an expulsion proceeding?
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Yes
No
Has this child been retained?
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Yes
No
Has this child met all the requirements of the Arkansas State Health laws necessary to enter school?
*
Yes
No
List names of anyone who is NOT allowed to check out/pickup your child from school.
Your answer
Please list any siblings your child has that attend school in the Warren School District. (names and school they attend)
Your answer
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