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

Student's SSN:
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Grade:

Reaquired field: 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:

Reaquired field: 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

Reaquired field: PARENT/GUARDIAN #1 FIRST NAME:
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Reaquired field: PARENT/GUARDIAN #1 LAST NAME:
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PARENT/GUARDIAN #1 Relationship to Student:
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PARENT/GUARDIAN #1 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

PARENT/GUARDIAN #1 Email Address:

PARENT/GUARDIAN #1 Home Phone:

PARENT/GUARDIAN #1 Cell Phone:

PARENT/GUARDIAN #1 Alert Phone:

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PARENT/GUARDIAN #1 Work Phone:

PARENT/GUARDIAN #1 Employer:
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Reaquired field: PARENT/GUARDIAN #2 FIRST NAME:
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Reaquired field: PARENT/GUARDIAN #2 LAST NAME:
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PARENT/GUARDIAN #2 Relationship to Student:
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PARENT/GUARDIAN #2 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

PARENT/GUARDIAN #2 Email:

PARENT/GUARDIAN #2 Home Phone:

PARENT/GUARDIAN #2 Cell Phone:

PARENT/GUARDIAN #2 Alert Phone:

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PARENT/GUARDIAN #2 Work Phone:

PARENT/GUARDIAN #2 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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ADDITIONAL GUARDIAN/CONTACT FIRST NAME:
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ADDITIONAL GUARDIAN/CONTACT LAST NAME:
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ADDITIONAL GUARDIAN/CONTACT Relationship to Student:
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ADDITIONAL GUARDIAN/CONTACT Language of Correspondence:
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ADDITIONAL GUARDIAN/CONTACT 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

ADDITIONAL GUARDIAN/CONTACT Home Phone:

ADDITIONAL GUARDIAN/CONTACT Cell Phone:

ADDITIONAL GUARDIAN/CONTACT Alert Phone:

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ADDITIONAL GUARDIAN/CONTACT Work Phone:

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

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

EMERGENCY Contact #1 Type of Phone?

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

EMERGENCY Contact #2 Type of Phone?

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

EMERGENCY Contact #3 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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Reaquired field: Parent/Guardian Signature
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Reaquired field: Date of Submission: