wynne primary school student registration
WYNNE PRIMARY SCHOOL STUDENT REGISTRATION Entry Date:____________________GRADE:_________________GRADUATION YEAR:________ TEACHER:______________________________________________________________________ FIRST NAME:
Gender: FEMALE
MIDDLE NAME:
LAST NAME:
MALE (circle one)
Nickname:__________________________
Birth Date:________________________
Social Security Number:____________________________
Hispanic/Latino Ethnicity Yes or No Student’s Primary Language__________________________
Student ID # (office use)___________________________ ESL STUDENT: Yes or No
RACE Please answer the following in accordance with standards issued by the US Department of Education. PRIMARY RACE (Please select only ONE.) _____American 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 attachment.) _____Asian (A person having origins in any of the original peoples of Far East, Southeast Asia or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam) _____Black or African American (A person having origins in any of the black racial groups of Africa) _____Native Hawaiian or Other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands) _____White (A person having origins in any of the original peoples of Europe, Middle East or North Africa) ADDITIONAL RACES (check all that apply) ____American Indian/Alaska Native ____Asian
_____Black
_____Native Hawaiian/Other pacific Islander
Student Physical/911 Address
_____White
Student Mailing Address
Address:__________________________________________
_____ Check if Mailing Address is same as Physical/911 Address PO Box/Street or Rural Rd______________________________
City______________________________________________
City:_______________________________________________
State:_________ Zip code:___________________________
State:__________ Zip code:____________________________
**PRIMARY CONTACT NUMBER:_________________________________**Number used for automated phone message system Legal Guardian Status: (circle one) MOTHER FATHER BOTH PARENTS GRANDPARENTS FOSTER PARENTS Lives with Legal Guardian 1 Lives with Legal Guardian 2 Name:______________________________________________ Name:______________________________________________ Relationship to student:________________________________
Relationship to student:_______________________________
Guardian Primary Language:___________________________ Language of Correspondence:__________________________ Email Address:_______________________________________
Guardian Primary Language:__________________________ Language of Correspondence:_________________________ Email Address:_____________________________________
Primary Contact Phone:_________________________ Work Phone:__________________________________ Cell Phone:____________________________________
*Primary Contact Phone:______________________________ Work Phone:________________________________________ Cell Phone:_________________________________________
Employer :____________________________________________
Employer:________________________________________________
Emergency Contact Person:__________________________Phone number:_______________________ Relationship to student:______________________________
Please continue to other side.
WYNNE PRIMARY SCHOOL STUDENT REGISTRATION ADDITIONAL STUDENT INFORMATION Page 2 _____________________________________________________________________________________________________________________
City of Birth:_______________________ State of Birth:____________ Country:___________________ Birth Certificate provided? Yes No
Birth Certificate Number:_______________________________
Is the student eligible for Medicaid/AR Kids First? Yes or No If YES, ID number_________________________________ Is this child a twin (triplet, quadruplet, etc.)? Yes No Has this child met the requirements of the Arkansas State Health Laws necessary to enter school? Yes No (Health Physical and Up to date Immunizations)
TRAVEL INFORMATION Travel TO School (Please check one) ____Bus (Bus number_______)
Travel FROM School (Please check one) ____Bus (Bus number_____)
____Parent/Guardian Car rider
_____Parent Guardian Car rider _____Child Care Van/Counseling Van
How Many Miles From School Does Student Live? (Miles One Way)_________
Previous School Information Name of School:_____________________________________Address:_________________________ City:__________________________State:___________Zip:____________Phone:________________ Last date attended:___________________________ Has the student ever attended school in the Wynne District before?___________ Is the student currently suspended, expelled or involved in expulsion proceedings from another district?______
Pre-School Participation A-ARKANSAS BETTER CHANCE (ABC) E-EVEN START EC-EARLY CHILDHOOD NAME OF PRE-SCHOOL:
H-HEADSTART PS-PUBLIC SCHOOL PRE-SCHOOL C-21ST CENTURY COMMUNITY LEARNING CENTER
O-OTHER P-PRIVATE PRE-SCHOOL N/A-NOT APPLICABLE
McKinney Vento Act Eligibility Is your family currently experiencing an unusual hardship due to loss of job, income or housing which has caused you to live in a doubled-up situation? Yes No Is this child a foster child? Yes No
MIGRANT PROGRAM ELIGIBILITY Did the student move alone or with parents?________________ Has an adult family member worked in an agriculturally related job in the last 3 years?____________________
MILITARY DEPENDENT INFORMATION Is this child a dependent of an active or reserve member of a branch of the United States Armed Forces? Yes No If this child resides in a household with an active or reserve member of a branch of the Armed Forces, please select the branch below. ____Active Duty ____Reserves ____Army ____Air Force ____Navy ____Marines ____Coast Guard _____National Guard ____Parents serve in multiple branches
List the names and birthdates of other children who are living in the home: __________________________ ___________________________ ____________________________________ __________________________ ___________________________ _____________________________________ Directions to home address:_______________________________________________________________________
SIGNATURE OF PARENT OR LEGAL GUARDIAN:_______________________________________________ The Wynne School District does not discriminate on the basis of race, religious creed, national origin, physical handicap, sex or race.
WYNNE PRIMARY SCHOOL STUDENT REGISTRATION ADDITIONAL STUDENT INFORMATION Page 2 _____________________________________________________________________________________________________________________
_____________________________________________________________________________________________
SIGNATURE OF PARENT OR LEGAL GUARDIAN:_______________________________________________ The Wynne School District does not discriminate on the basis of race, religious creed, national origin, physical handicap, sex or race.
Gender: FEMALE
MIDDLE NAME:
LAST NAME:
MALE (circle one)
Nickname:__________________________
Birth Date:________________________
Social Security Number:____________________________
Hispanic/Latino Ethnicity Yes or No Student’s Primary Language__________________________
Student ID # (office use)___________________________ ESL STUDENT: Yes or No
RACE Please answer the following in accordance with standards issued by the US Department of Education. PRIMARY RACE (Please select only ONE.) _____American 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 attachment.) _____Asian (A person having origins in any of the original peoples of Far East, Southeast Asia or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam) _____Black or African American (A person having origins in any of the black racial groups of Africa) _____Native Hawaiian or Other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands) _____White (A person having origins in any of the original peoples of Europe, Middle East or North Africa) ADDITIONAL RACES (check all that apply) ____American Indian/Alaska Native ____Asian
_____Black
_____Native Hawaiian/Other pacific Islander
Student Physical/911 Address
_____White
Student Mailing Address
Address:__________________________________________
_____ Check if Mailing Address is same as Physical/911 Address PO Box/Street or Rural Rd______________________________
City______________________________________________
City:_______________________________________________
State:_________ Zip code:___________________________
State:__________ Zip code:____________________________
**PRIMARY CONTACT NUMBER:_________________________________**Number used for automated phone message system Legal Guardian Status: (circle one) MOTHER FATHER BOTH PARENTS GRANDPARENTS FOSTER PARENTS Lives with Legal Guardian 1 Lives with Legal Guardian 2 Name:______________________________________________ Name:______________________________________________ Relationship to student:________________________________
Relationship to student:_______________________________
Guardian Primary Language:___________________________ Language of Correspondence:__________________________ Email Address:_______________________________________
Guardian Primary Language:__________________________ Language of Correspondence:_________________________ Email Address:_____________________________________
Primary Contact Phone:_________________________ Work Phone:__________________________________ Cell Phone:____________________________________
*Primary Contact Phone:______________________________ Work Phone:________________________________________ Cell Phone:_________________________________________
Employer :____________________________________________
Employer:________________________________________________
Emergency Contact Person:__________________________Phone number:_______________________ Relationship to student:______________________________
Please continue to other side.
WYNNE PRIMARY SCHOOL STUDENT REGISTRATION ADDITIONAL STUDENT INFORMATION Page 2 _____________________________________________________________________________________________________________________
City of Birth:_______________________ State of Birth:____________ Country:___________________ Birth Certificate provided? Yes No
Birth Certificate Number:_______________________________
Is the student eligible for Medicaid/AR Kids First? Yes or No If YES, ID number_________________________________ Is this child a twin (triplet, quadruplet, etc.)? Yes No Has this child met the requirements of the Arkansas State Health Laws necessary to enter school? Yes No (Health Physical and Up to date Immunizations)
TRAVEL INFORMATION Travel TO School (Please check one) ____Bus (Bus number_______)
Travel FROM School (Please check one) ____Bus (Bus number_____)
____Parent/Guardian Car rider
_____Parent Guardian Car rider _____Child Care Van/Counseling Van
How Many Miles From School Does Student Live? (Miles One Way)_________
Previous School Information Name of School:_____________________________________Address:_________________________ City:__________________________State:___________Zip:____________Phone:________________ Last date attended:___________________________ Has the student ever attended school in the Wynne District before?___________ Is the student currently suspended, expelled or involved in expulsion proceedings from another district?______
Pre-School Participation A-ARKANSAS BETTER CHANCE (ABC) E-EVEN START EC-EARLY CHILDHOOD NAME OF PRE-SCHOOL:
H-HEADSTART PS-PUBLIC SCHOOL PRE-SCHOOL C-21ST CENTURY COMMUNITY LEARNING CENTER
O-OTHER P-PRIVATE PRE-SCHOOL N/A-NOT APPLICABLE
McKinney Vento Act Eligibility Is your family currently experiencing an unusual hardship due to loss of job, income or housing which has caused you to live in a doubled-up situation? Yes No Is this child a foster child? Yes No
MIGRANT PROGRAM ELIGIBILITY Did the student move alone or with parents?________________ Has an adult family member worked in an agriculturally related job in the last 3 years?____________________
MILITARY DEPENDENT INFORMATION Is this child a dependent of an active or reserve member of a branch of the United States Armed Forces? Yes No If this child resides in a household with an active or reserve member of a branch of the Armed Forces, please select the branch below. ____Active Duty ____Reserves ____Army ____Air Force ____Navy ____Marines ____Coast Guard _____National Guard ____Parents serve in multiple branches
List the names and birthdates of other children who are living in the home: __________________________ ___________________________ ____________________________________ __________________________ ___________________________ _____________________________________ Directions to home address:_______________________________________________________________________
SIGNATURE OF PARENT OR LEGAL GUARDIAN:_______________________________________________ The Wynne School District does not discriminate on the basis of race, religious creed, national origin, physical handicap, sex or race.
WYNNE PRIMARY SCHOOL STUDENT REGISTRATION ADDITIONAL STUDENT INFORMATION Page 2 _____________________________________________________________________________________________________________________
_____________________________________________________________________________________________
SIGNATURE OF PARENT OR LEGAL GUARDIAN:_______________________________________________ The Wynne School District does not discriminate on the basis of race, religious creed, national origin, physical handicap, sex or race.
