School Registration Form 2018-2019

Family Information

Father/Guardian

Relationship status

Married
Single
Divorced
Separated

Address

Street Address City State ZIP Code

Home Phone

Work Phone

Cell Phone

Employer

Email

Military Status: Active?

Yes
No

Military Status: Deployed?

Yes
No

Branch

Mother/Guardian

Relationship status

Married
Single
Divorced
Separated

Address

Street Address City State / Province / Region ZIP / Postal Code

Home Phone

Work Phone

Cell Phone

Employer

Email

Military Status: Active?

Yes
No

Military Status: Deployed?

Yes
No

Branch

Children living with:*

Emergency Information

Emergency contact*

Relationship to student*

Address*

Street Address City State / Province / Region

Work Phone

Cell Phone*

Emergency contact*

Relationship to student*

Address*

Street Address City State / Province / Region

Work Phone

Cell Phone*

Doctor*

Phone*

Doctor

Phone

Dentist*

Phone*

Hospital Choice*

Phone*

Address*

Street Address City

Every effort will be made to notify parents/guardians immediately in case of emergency. In the event that my child may require medical attention and I am unable to be reached, I hereby give my consent to medical treatment to the GEORGE-LITTLE ROCK SCHOOL and Doctor/Dentist or his or her designee to provide this care. I agree to pay all the costs and fees contingent on any emergency medical care and/or treatment for my child as secured or authorized under this consent.*

Yes
No

Parent Signature*

Student Information

Student's Legal Name*

Grade*

Gender*

Birthdate*

Birthplace*

Social Security Number*

Ethnicity*

Hispanic or Latino
Non-Hispanic or Latino

Race (check all that apply)*

Asian
Black-African American
American Indian-Alaska Native
Hawaiian/Pacific Islander
White
Other

Student's Legal Name

Grade

Gender

Birthdate

Birthplace

Social Security Number

Ethnicity

Hispanic or Latino
Non-Hispanic or Latino

Race (check all that apply)

Asian
Black-African American
American Indian-Alaska Native
Hawaiian/Pacific Islander
White
Other

Student's Legal Name

Grade

Gender

Birthdate

Birthplace

Social Security Number

Ethnicity

Hispanic or Latino
Non-Hispanic or Latino

Race (check all that apply)

Asian
Black-African American
American Indian-Alaska Native
Hawaiian/Pacific Islander
White
Other

Student's Legal Name

Grade

Gender

Birthdate

Birthplace

Social Security Number

Ethnicity

Hispanic or Latino
Non-Hispanic or Latino

Race (check all that apply)

Asian
Black-African American
American Indian-Alaska Native
Hawaiian/Pacific Islander
White
Other

Student's Legal Name

Grade

Gender

Birthdate

Birthplace

Social Security Number

Ethnicity

Hispanic or Latino
Non-Hispanic or Latino

Race (check all that apply)

Asian
Black-African American
American Indian-Alaska Native
Hawaiian/Pacific Islander
White
Other

Parental/Guardian Consent

My child/children have permission to have breakfast:*

Yes
No

My child/children have permission to have ala-carte items:*

Yes
No

My child/children have permission to take the school-sponsored trips throughout the year for which a note will be sent home informing me of such field trips before they occur:*

Yes
No

I give permission to use photographs of my child/children participating in school and/or school-related programs and activities for the purpose of public relations:*

Yes
No

My child/children have permission to be released to the emergency contacts above if I cannot be reached:*

Yes
No

I give permission for the following persons to pick up my child/children. It is the responsibility of the parents to notify the school in writing of any changes.*

Individuals NOT allowed to pick up my child/children:

Parent Signature*

Family Information

Emergency Information

Student Information

Parental/Guardian Consent

If you would like information about GLR schools or if there is any way we can assist you, please do not hesitate to contact us. We would love to give you more information about any of our schools.

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