MINERAL SPRINGS

How will your child ATTEND SCHOOL for the 2020-2021 School Year?

Student's First Name:
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Student's Middle Name:
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Student's Last Name:
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Student's Nickname:
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Student's Birthdate

Student's SSN:
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Grade:

PRIMARY RACE

Select OneAMERICAN 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 attachmentASIAN - A person having origins in any of the original peoples of Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, Chine, India, Japan, Korea, Malaysia, Pakistan, the Philippine Isalnds, Thailand and VietnamBLACK or AFRICAN AMERICAN - A person having origins in any of the black racial groups of AfricaNATIVE HAWAIIAN or OTHER PACIFIC ISLANDER - A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific IslandsWHITE - A person having origins in any of the original peoples of Europe, Middle East or North Africa

Hispanic/Latino Ethnicity:

Language Spoken at Home?
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Student Home Phone:

Student Cell Phone:

Student Email Address:

Address
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City
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State / Province / Region
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Zipcode Min: 1 Max: 5
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Country

Address
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City
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State / Province / Region
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Zipcode Min: 1 Max: 5
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Country

FIRST NAME:
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LAST NAME:
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Relationship to Student:
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Language of Correspondence:
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Address
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City
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State / Province / Region
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Zipcode Min: 1 Max: 5
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Country

Email Address:

Home Phone:

Cell Phone:

Alert Phone:

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Work Phone:

Employer:
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FIRST NAME:
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LAST NAME:
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Relationship to Student:
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Language of Correspondence:
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Address
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City
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State / Province / Region
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Zipcode Min: 1 Max: 5
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Country

Email:

Home Phone:

Cell Phone:

Alert Phone:

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Work Phone:

Employer:
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Student's City of Birth:
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Student's State of Birth:
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Student's Birth Country:
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Student travels TO school by:

Student travels FROM school by:

If your student travels by bus, what is the bus number?
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What is the distance from Home to School (Miles) one way?
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Pre-School Participation (if applicable)

Student's Birth Certificate Number:
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Student's Resident County:
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Is this child a dependent of an active or reserve member of a branch of the United States Armed Services?

Is this student a twin (or a triplet, quadruplet, etc.)?
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FIRST NAME:
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LAST NAME:
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Relationship to Student:
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Language of Correspondence:
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Email:

Address
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City
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State / Province / Region
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Zipcode Min: 1 Max: 5
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Country

Home Phone:

Cell Phone:

Alert Phone:

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Work Phone:

Employer:
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Does student reside with this Additional Guardian/Contact?

EMERGENCY Contact #1 Name:
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Relationship to Student:
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Language of Correspondence
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Phone:

Type of Phone?

EMERGENCY Contact #2 Name:
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Relationship to Student?
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Language of Correspondence
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Phone:

Type of Phone?

EMERGENCY Contact #3 Name:
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Relationship to Student:
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Language of Correspondence
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Phone:

Type of Phone:

Student's Physician:
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Physician's Phone Number:

Please list any medical conditions, concerns, and/or medications for your child.

Last School Attended:
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Address/Phone of Last School Attended:
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Has this child been retained?

Has this child met the requirements of the Arkansas State Health laws necessary to enter school?

Please list the names of anyone who IS ALLOWED to check out/pick up this child from school:
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Parent/Guardian Signature
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Date of Submission: