Admin

NACS Elementary Enrollment Form

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 __________________________________________________________________