STUDENT ENROLLMENT FORM

Select grade* Select grade*3Pk4PkKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th Grade

Student's first name*

Student's middle name

Student's last name*

Birthdate & Birth Place

Social security number (MUST HAVE A COPY IN STUDENT FILE)*

Are you of Hispanic/Latino culture or origin? Are you of Hispanic/Latino culture or origin? Yes No

Race (choose one or more) Race (choose one or more) American Indian or Alaskan Native Asian Black/African American White Native Hawaiian or Other Pacific Islander

Has the student ever attended Wanette Public Schools?* Has the student ever attended Wanette Public Schools?* Yes No

If so, when? (mm/dd/yyyy)*

Does your child use a name other than his/her legal name?* Does your child use a name other than his/her legal name?* Yes No

Student's residential address*

City*

Zip Code*

If so, what is it?*

Student's mailing address*

City*

Zip Code*

Is student's mailing address the same as the physical address listed above?* Is student's mailing address the same as the physical address listed above?* Yes, it's the same. No, it's different.

How far—in miles—do you live from the school?*

Will your child be driving to and from school?* Will your child be driving to and from school?* Yes No

Vehicle make*

Is the residential address owned by the Indian Housing Authority or located on Indian land?* Is the residential address owned by the Indian Housing Authority or located on Indian land?* Yes No

Vehicle color*

Student's driver's license and state*

Does your child reside in the Wanette Public School District?* Does your child reside in the Wanette Public School District?* Yes No

Vehicle model*

Home phone number*

Student's cell number

If no, what district?*

Gender (of above parent/legal guardian)*

Relation to child* Relation to child* Parent Legal guardian

Legal parent or guardian #1 full name*

Able to pick up child?* Able to pick up child?* Yes No

Send mail/report card?* Send mail/report card?* Yes No

Does child reside with you?* Does child reside with you?* Yes No

Work phone

Home phone

Mailing address*

Cell phone

Zip code*

City*

Email

Place of employment

Occupation

Gender (of above parent/legal guardian)*

Legal parent or guardian #2 name (if any)

Does child reside with you?* Does child reside with you?* Yes No

Relation to child* Relation to child* Parent Legal guardian

Send mail/report card?* Send mail/report card?* Yes No

Able to pick up child?* Able to pick up child?* Yes No

Work phone

Home phone

Mailing address*

Cell phone

City*

Zip code*

Email

Place of employment

Occupation

Is the custody of this child decreed by the courts?* Is the custody of this child decreed by the courts?* Yes No

Who has primary?*

Relationship to the child*

Is either parent/guardian in the military or a civilian working on government property?* (Eligible government properties: FFA-Will Rogers Airport, Any Indian Casinos, Indian Health Services, Federal Highway Administration, U.S. Postal Service, VA Medical Center, U.S. Geological Survey, Uniformed Services (National Guard, Army, Air Force, Marines, Navy, Navy Reserves, etc.) Is either parent/guardian in the military or a civilian working on government property?* (Eligible government properties: FFA-Will Rogers Airport, Any Indian Casinos, Indian Health Services, Federal Highway Administration, U.S. Postal Service, VA Medical Center, U.S. Geological Survey, Uniformed Services (National Guard, Army, Air Force, Marines, Navy, Navy Reserves, etc.) Yes No

If yes, who?*

Emergency contact #1 name

Gender*

Relation to child*

Home Phone

Work Phone

Cell Phone

Gender*

Relation to child*

Home Phone

Work Phone

Emergency contact #2 name

Name of last school attended, if applicable

Address of last school attended*

City*

State*

Cell Phone

Phone*

Fax

Is the student currently under suspension at previous school?* Is the student currently under suspension at previous school?* Yes No

Zip code*

Has student been in any type of special program(s)? (Check all that apply) Has student been in any type of special program(s)? (Check all that apply) Gifted/Talented Special Ed (IEP) English Language Learner (ELL) 504 Speech Title VII/JON Reading/HOSTS Other

Does your child participate in a childcare program licensed by DHS?* Does your child participate in a childcare program licensed by DHS?* Yes No

Does your child participate in the Sooner Start program?* Does your child participate in the Sooner Start program?* Yes No

Name & grade of ALL other children in household currently enrolled at Wanette Public Schools

Does your child participate in the Children First program or any other child abuse prevention program operated by the State Dept. of Health?* Does your child participate in the Children First program or any other child abuse prevention program operated by the State Dept. of Health?* Yes No

Does your child participate in the Head Start program or any other childhood program funded by state or federal monies?* Does your child participate in the Head Start program or any other childhood program funded by state or federal monies?* Yes No

If you answered yes to any of the above five questions, please provide the name, address, and phone number of the services provided.

Does your child participate in the Oklahoma Parents as Teachers program operated by the State Dept. of Education?* Does your child participate in the Oklahoma Parents as Teachers program operated by the State Dept. of Education?* Yes No

Does your home have internet access?* Does your home have internet access?* Yes No

Is there a device for distance learning available for the child to use?* Is there a device for distance learning available for the child to use?* Yes No

I choose to enroll my child in all-virtual schooling.* I choose to enroll my child in all-virtual schooling.* Yes No

I give permission for my child to have access to the Wanette Public School's network and the internet.* I give permission for my child to have access to the Wanette Public School's network and the internet.* Yes No

I give permission for my child's picture to be used in school publication (website, TV, newspaper, etc.).* I give permission for my child's picture to be used in school publication (website, TV, newspaper, etc.).* Yes No

If so, what type of device is available for your child to use?*

I give permission for my child to participate in away sports games (baseball, basketball, softball).* I give permission for my child to participate in away sports games (baseball, basketball, softball).* Yes No

I give permission for my child to receive free vision and hearing screenings and any other screening test.* I give permission for my child to receive free vision and hearing screenings and any other screening test.* Yes No

I give permission for my child to participate in class field trips (info will be sent home prior to each trip).* I give permission for my child to participate in class field trips (info will be sent home prior to each trip).* Yes No

Do you have any degree of American Indian ancestry or have a CDIB card?* Do you have any degree of American Indian ancestry or have a CDIB card?* Yes No Yes, but I don't have an ID number, or don't know where it is.

I give permission for my child to be given Tylenol, Ibuprofen, cough syrup/drops, provided by the parents with your child's name on the bottles or bag of cough drops.* I give permission for my child to be given Tylenol, Ibuprofen, cough syrup/drops, provided by the parents with your child's name on the bottles or bag of cough drops.* Yes No

The school has consent for corporal punishment (you will be notified before administering corporal punishment).* The school has consent for corporal punishment (you will be notified before administering corporal punishment).* Yes No

Indian ID #*

Please list all allergies and medical conditions the school might need to know about.*

Does your child have any allergies (bee stings, food, drug) or any other medical problems we need to know about?* Does your child have any allergies (bee stings, food, drug) or any other medical problems we need to know about?* Yes No

Medical information will be shared with appropriate school personnel. In the event I cannot be reached and my child needs treatment that cannot be taken care of at school, I do hereby authorize the designated school employee to take my child to the nearest hospital for treatment.* Medical information will be shared with appropriate school personnel. In the event I cannot be reached and my child needs treatment that cannot be taken care of at school, I do hereby authorize the designated school employee to take my child to the nearest hospital for treatment.* Yes No

Pursuant to the School Laws of Oklahoma, Wanette Public Schools has adopted a board policy prohibiting the attendance of a student under suspension from another school, until such times as the terms of the suspension have been met or suspension expired. The circumstances of an individual's suspension may be reviewed. By signing this form, I do hereby affirm that the student listed above is not currently under suspension from another school district.* Pursuant to the School Laws of Oklahoma, Wanette Public Schools has adopted a board policy prohibiting the attendance of a student under suspension from another school, until such times as the terms of the suspension have been met or suspension expired. The circumstances of an individual's suspension may be reviewed. By signing this form, I do hereby affirm that the student listed above is not currently under suspension from another school district.* Yes, I agree.

I also affirm that the facts stated herein are true. Any false statement subjects the above named student to immediate withdrawal.* I also affirm that the facts stated herein are true. Any false statement subjects the above named student to immediate withdrawal.* Yes, I agree.

Parent/guardian signature*

Date*