rush springs high school

RUSH SPRINGS HIGH SCHOOL BASIC STUDENT INFORMATION

Students Legal Last Name Date of Birth (MM/DD/YYYY) Place of Birth ______________________________ (city/state)

Current Grade_______ Name of Last School Attended:

First Name Preferred Name Sex ____ Male ____ Female Is this student Hispanic/Latino _______Yes ________NO What Language is Spoken at home:

Middle Name

Primary Phone Number ( )_______ - ____________ Race _____American Indian/Alaska Native _____Asian _____African American _____Native Hawaiian/Pacific Islander _____Caucasian _____Other

DEMOGRAPHIC INFORMATION

FAMILY’S PHYSICAL HOME ADDRESS FAMILY’S MAILING ADDRESS Street Apt # County Street or Count Road /PO Apt # City State Zip City State Zip ** Is the student a transfer living in another School District? ______ YES ______ NO If Yes, Which School District? ___________________________________

WITH WHOM DOES THE CHILD RESIDE (CHOOSE ONLY ONE) _____Both Parents ______Mother Only ______Father Only ______Mother & Step-Father ______Father & Step-Mother ______ Legal Guardian CIRCLE ONE CIRCLE ONE FATHER OR STEP-FATHER MOTHER OR STEP-MOTHER

First Name Last Name Address Home Phone Cell Phone Employer Work Phone Email



First Name Last Name Address Home Phone Cell Phone Employer Work Phone Email



EMERGERCY CONTACTS (OTHER THAN PARENTS) FIRST NAME

1. 2. 3.

LAST NAME

RELATIONSHIP TO STUDENT

HOME PHONE

CELL PHONE

























Please list anyone who has permission to pick up/check out of school, please list the name and relationship to child: 1.__________________________________________________________________________________________________________ 2.__________________________________________________________________________________________________________ 3.__________________________________________________________________________________________________________ ** STUDENTS MUST HAVE A COMPLETE IMMUNIZATION RECORD ON FILE WITH RUSH SPRINGS HIGH SCHOOL WITHIN 30 DAYS OF ENROLLMENT

HEALTH INFORMATION

FAMILY DOCTOR

PHONE NUMBER

MEDICAL CONDITIONS PRESCRIPTION MEDICATIONS

TRANSPORTATION

DOES THE STUDENT LIVE MORE THAN 1.5 MILES FROM SCHOOL? _______ YES _______ NO Student will be transported to/from school by: BUS or CAR Bus Number _______ Will the student be driving to school? ______ YES _______ NO Vehicle Make and Model : __________________________________________________________________ __________________________________________________ _______________________________ PARENT/GUARDIAN SIGNATURE DATE