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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

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

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)

Name (18 or older)	Relationship	Phone Number	DL or State ID#