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    Middle School New Student Enrollment 
     
    First Name:_______________Middle Name:_______________Last Name :_______________________

    Address:________________________________City:____________________State: IN  Zip:_________

    Home Phone:___________________________  Grade:______     Birthdate:_______/_______/_______    

    Social Security Number:______ - ______ - ______(optional)                               Gender:      M       F

    Student’s Cell Phone # _____________________________________ (optional)

    U.S. citizen?       Yes     No      If no, what country ________________/U.S. Entry Date ______________

    Ethnic Backround:          1._____American Indian/Alaskan           4._____Hispanic

                                            2._____Black/Non-Hispanic                   5._____White/Non-Hispanic

                                            3._____Asian or Pacific Islander            6._____Multiracial

    Mother’s First Name:______________________Mother’s Last Name:__________________________

    Mother’s Address___________________________________________________________________

    City_____________________State__________Zip____________ Home Phone_________________

    Mother’s Employer:___________________________ Work Phone #___________________________

    Mother’s Cell Phone #_____________________      Resides with Mother?   Y    N

    Mother’s E-mail Address______________________________________________________________


    Father’s First Name:______________________Father’s Last Name:__________________________

    Father’s Address___________________________________________________________________

    City___________________State__________Zip____________Home Phone #__________________

    Father’s Employer:________________________________  Work Phone #_____________________

    Father’s Cell Phone #______________________   Resides with Father?    Y    N

    Father’s E-mail Address_____________________________________________________________


    Emerg. Contact 1(other than parent)______________________________Phone #________________

    Contact 1’s Relationship to Student_________________________

    Emerg. Contact 2(other than parent)______________________________Phone #________________

    Contact 2’s Relationship to Student_________________________


    Former School_______________________ City & State_________________Date Left___________

    Phone #________________________ Counselor/Contact__________________________________

    Is your student currently suspended/expelled from former school?                  Yes    No

    Has student been suspended/expelled from former school in the past year?    Yes    No

    Has your student ever been enrolled in a NACS school before?                        Yes    No

    Does your student have an active IEP (special education) or 504 plan?           Yes    No

    Are you applying for free/reduced lunches & textbook assistance?                  Yes    No


    FYI - Upon entering school, all students must meet Indiana State law requirements for immunization.  Please note that the law provides for exclusion from school for failure to comply with the immunization law, unless a parent provides a written religious or medical objection. 

    Minimum Dosage is as follows:  DIPHTERIA, TETANUS, PERTUSSIS – 4 Doses  **3 doses acceptable if the third dose was administered at age 6 or older.  ORAL POLIO – 3 Doses            MEASLES, MUMPS, RUBELLA  - 2 Doses

    Effective August/2006 – Hepatitis B series required for grades 9, 10, and 12