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Student Registration
Student Last Name, First Name, Middle Name*
Student Birthdate*
Student Gender
Student ID Number*
Current Grade
Previous School/Address*
Parent/Guardian Name*
Parent/Guardian Email*
Phone Number*
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Parent/Guardian Address*
City, State, ZIP Code
Student Primary Residence (If Different From Above)
City, State, ZIP Code
Emergency Contact
Name
Phone Number
Relationship
Student Registration pg 2
Physician/Medical Information
Physician Name*
Physician Phone Number
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Preferred Hospital
Health Insurance Provider*
Please list any areas of concern: (Medication allergies, food/insect allergies, chronic health conditions, current medications, etc.)*
Pick Up Permission
Parent/Guardian gives permission for student to leave school campus with:
Name (18 or older)
Relationship
Phone Number
DL or State ID#
Signature and Date*
Documents Required for Registration*
Birth Certificate Parent/Guardian Driver License or State ID Current Immunization Record Proof of Residence (gas/water/electric bill, mortgage/rent payment receipt)

Student Registration