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Ovid-Elsie Area Schools – Student Registration Form Student Information Date:

Start Date :

Entering grade:

Building:

Student Legal Name:

Gender: M F Last

First

Preferred/Nick Name:

Middle

Birth date:

/

Suffix

/

Nick Name

Birthplace: City

State

Social Security Number: Race/Ethnicity:

White, non Hispanic

Hispanic

Black, non Hispanic

Am Indian/Alaskan Native

Asian

Pacific Islander

Multiethnic If multiethnic is chosen please indicate primary race with a 1, followed by a 2 for the secondary ethnicity, etc. Does your child receive Special Education services? Yes No If yes, type of service Student’s school previously attended:

Address:

Has your child attended Ovid-Elsie Area Schools previously? Yes No Has your child ever been suspended from any school? Yes No If yes, why? Please list any current legal court documents or restraining orders pertaining to this student. A copy of this information must be provided to the district.

Please list other children in your household in order of oldest to youngest. Name: Name: Name: Name: Name: Name:

Birthdate: Birthdate: Birthdate: Birthdate: Birthdate: Birthdate:

/ / / / / /

/ / / / / /

M M M M M M

F F F F F F

Grade: Grade: Grade: Grade: Grade: Grade:

Primary Household Information Household Address: Number City

State

N/S/E/W

Street Name

Apt/Lot#

Primary Household Phone: ( County:

Zip

With whom does the student reside (primary residence)?

PO Box )

Joint Custody?

Mother/Father

Mother/Stepfather

Mother Only

Father/Stepmother

Father Only

Other:

Parent/Guardian Info Name – (Parent, Step-parent, Other)

Legal Guardian?

Female

Last

Yes

First

Middle

Suffix

Last

Cell phone (include area code) Work phone (include area code) Email address (District purposes only)

Office Use Only: Student ID#

Grade entering

Legal Guardian?

Male

No

Building

Yes No

Yes

First

Middle

No

Suffix


Student Name: Secondary Household Information Does the student have a parent at a second residence? Yes No

Joint Custody? Yes

No

Household Address: Number City

State

N/S/E/W

Street Name Apt/Lot# Household Phone: (

PO Box

)

Zip

Mother Only

Stepmother/Bio Father

Other:

Father Only Stepfather/Bio Mother Biological parents will receive mailing and access to student information unless court documentation supplied indicates otherwise.

Second Household Data:

Legal Guardian?

Female

Yes

Legal Guardian?

Male

No

Yes

No

Name – (Parent, Step-parent, Other)

Last

First

Middle

Suffix

Last

First

Middle

Suffix

Cell phone (include area code) Work phone (include area code) Email address (District purposes only)

Emergency Contact Information Household Emergency Contact Information (Parents/Stepparents/Guardians) Number from 1 to 4 the order these should be contacted (if applicable): Stepmother

Stepfather

Other:

Mother

Father

Other: Name

Name

Non-Household Emergency Contact Information (if no Parent/Guardian is available) 1. Name:

Gender: M Last

First

Middle

Relationship to student: Cell phone number: (

House phone number: ( )

F

Suffix

Work phone number: (

)

)

2. Name:

Gender: M Last

First

Middle

Relationship to student: Cell phone number: (

Telephone number: ( )

F

Suffix

Work phone number: (

)

)

Health History Please circle current medical conditions: Asthma ADD/ADHD Bee Stings

Diabetes

Other:

Other:

Drug Allergy

EPI-pen

Food Allergy

Seizure

If Drug and/or Food allergy is circled, specify what this student is allergic to: Please list prescribed medications currently taken by this student: Please note: All medications taken at school must follow Michigan Law, which requires schools to have a written physician’s order and parent/guardian authorization. (Medication Authorization forms available on line, at the school, or by calling 989 227-4902)

EMERGENCY CARE PERMISSION In case of serious illness or injury, I hereby request and give my full consent for authorized school personnel to transport my child directly to the nearest hospital, or send by ambulance if needed, and I will assume all financial obligations. I further authorize any licensed physician or dentist and/or hospital to provide necessary treatment. I understand this health information can be shared when it is educationally relevant for academic progress, necessary for providing health services including emergency care, or essential to ensure the protection of other students and school personnel. I understand this permission will continue to be in effect as long as the student is enrolled in Ovid-Elsie Area Schools, unless revoked in writing. Date

Signature of Parent/Guardian


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