• Office Use Only:      STN #_______________________    STN # Transferred _____   NACS #______________________

                                     Date Input __________   Start Date __________   Bus # ___________ Teacher_________________

    NACS Elementary Enrollment Form

    Student COMPLETE Name ________________________________________________Grade ____
                                                      Last                               First                           Middle
    Address ___________________________________________________________   Zip Code ________
     
    Home Phone (     )_________________Student Birth Date ________________       Male ___ Female ___
                                                                                  (copy of birth certificate required)
     
    Name of Housing Addition/Neighborhood: _______________________________________________
    Student Lives With:   Both Natural Parents ____ Guardian/Foster Parents ____
                                         Custodial Parent*(including joint custody) ___ One Natural/One Step-Parent*____                              
                                         Other (please explain) ________________________________________________
     
    Please list any special custody instructions here ______________________________________________
    *If there are any legal documents regarding custody or visitation, you are required to provide a copy to the school office.

    U.S. Citizen:  Yes ____ No ____ If born outside the U.S., give date of entry into the U.S. __________

    Physical Health Problems: ___________ Physician Name ____________ Physician Phone _________

    MOTHER: Name: ______________________ Does student reside with this parent? Yes _____ No ____

    Address (if different from Student) ________________________________________________________

    Home Phone ____________________ Work Phone _________________ Cell Phone________________

    Email Address________________________________Employer__________________________Ext. ___

    Parent has custody? Yes _____ No ______

     

    FATHER: Name: ______________________ Does student reside with this parent? Yes _____ No _____

    Address (if different from Student) ________________________________________________________

    Home Phone ____________________ Work Phone _________________ Cell Phone________________

    Email Address________________________________Employer__________________________Ext. ___

    Parent has custody? Yes _____ No ______

     

    STEP-PARENT INFORMATION – COMPLETE ONLY IF STUDENT LIVES WITH YOU:

    Name: _________________________________­­­­­­­­______________ Step-Mother or Step-Father (circle one)

    Address (if different from Student) ________________________________________________________

    Home Phone ____________________ Work Phone _________________ Cell Phone________________

    Email Address________________________________Employer__________________________Ext. ___

     

    STEP-PARENT INFORMATION – COMPLETE ONLY IF STUDENT LIVES WITH YOU:

    Name: _______________________________________________ Step-Mother or Step-Father (circle one)

    Address (if different from Student) ________________________________________________________

    Home Phone ____________________ Work Phone _________________ Cell Phone________________

    Email Address________________________________Employer__________________________Ext. ___

     

     

     

    EMERGENCY CONTACTS- These contacts will be called only when parents cannot be reached.

    Contact #1  Name ___________________________________Relationship to Student ______________

                        Home Phone __________________Work Phone_______________Cell Phone___________

    Contact #2  Name ___________________________________Relationship to Student ______________

                        Home Phone __________________Work Phone_______________Cell Phone___________

    Contact #3  Name ___________________________________Relationship to Student ______________

                        Home Phone __________________Work Phone_______________Cell Phone___________

    Contact #4  Name ___________________________________Relationship to Student ______________

                        Home Phone __________________Work Phone_______________Cell Phone___________

     

    Has this student ever attended any Northwest Allen County School? Yes ___ No___ If yes, when _____

    Siblings in Northwest Allen County Schools:

    Name ___________________________________________Grade _____ School __________________

    Name ___________________________________________Grade _____ School __________________

    Name ___________________________________________Grade _____ School __________________

     

    Will you be applying for free or reduced meals/textbook assistance or free Kindergarten milk?

    Yes ___ No ____ (If so, please ask for the necessary forms.)

    Did student participate in a Gifted/Talented program at previous school? Yes _____ No _____

     

    SPECIAL EDUCATIONAL SERVICES:

    The requested information will determine if a student is eligible for Special Services.

    1.     Has your child ever been evaluated for or received Special Education Services?  Yes ____ No _____

       If yes, explain type of service, where, when and given by whom. _____________________________    _________________________________________________________________________________

    2.     Has your child ever been evaluated for or received speech, hearing, or occupational therapy services?

          Yes _____ No _____ If yes, explain type of service, where, when and given by whom. ______________    ________________________________________________________________________

    3.  Does your child have an IEP (Individualized Education Plan)?  Yes ___________ No ____________

       What is the IEP for? ________________________________________________________________

    4.     My child has never received Special Education/Program Services, nor do I feel my child needs to receive Special Education Services at this time.

       Signature _________________________________________________________________________

    Signature of person enrolling student _______________________________­­­­­______ Date _____________

    Relationship to student __________________________________________________________________