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ENROLLMENT/WITHDRAWAL FORM Office Use Only
Has your child attended GB Schools in the past?
Yes
No
School Code:
Student's Name (Last, First, Middle):
Grade Enrolling Into:
Perm ID: UIC#
Birthdate:
Building: Gender: (circle)
Kdg Waiver?
Child's Birth Place (County/State): Yes
Enter Date:
Male
No
Birth Country:
Female
Student's Native Language:
Primary Language Spoken at Home: Primary Phone: □ Home □ Work □ Cell Ethnicity: *Hispanic/Latino?
Leave Date: ESL Screening? Yes
Yes
No
No
*A person of Cuban, Mexican, Puerto Rican, South or Central America or other Spanish culture/origin, regardless of race.
Address: City:
Race: *Circle one or more-use 1 & 2 to rank primary & secondary group Amer Ind or Alaskan Asian African Amer/Black Native Hawaiian/Pacific Islander White
Zip:
With whom does child live? (circle) Foster Care
Other
Both Parents
Mother/Stepdad
If eligible, will you use school busing? From home to school? From day care to school?
Yes
Yes
No
Yes
Father Only
Mother Only
Father/Stepmom
Blended Family
Physical Custody
Living on Own
Joint Custody
Day Care Name/Address:
No From school to home?
No
Legal Guardian
Yes
No
From school to day care? Yes No
Previous school:
if your child has received Special Education Services □ Currently □ Previously
City/State:
if your child has received 504 services □ Currently □ Previously
School Moving to: City/State:
if your child received Speech/Lang Therapy? □ Currently □ Previously
Has your child participated in other GB Programs? Yes No
□ Parents as Teachers □ Children's Garden □ GPGS
□ GSRP
Parent/Guardian Information Mother's Name:
Employer:
Address (if different than above) :
Internet at home?
Job Title: Yes
No
e-mail address: Mailings Allowed: □
Contact Allowed: □
Is Mom active in the Military? Level of Education Completed: Phone (first Contact ) : □ Home
Yes
Student Lives With Mom: □
Mom has custody: □
No
□ Work
Country of Birth: Date of Naturalization: □ Cell Phone (second contact ): □ Home □ Work
Father's Name:
Employer:
Address (if different than above) :
Internet at home?
□ Cell
Job Title: Yes
No
e-mail address: Mailings Allowed: □
Contact Allowed: □
Is Dad active in the Military? Yes No Level of Education Completed: Phone (first Contact ) : □ Home □ Work
Student Lives With Dad: □
Dad has custody: □
Country of Birth: Date of Naturalization: □ Cell Phone (second contact ): □ Home □ Work
□ Cell
Other Children in the Family Name
Birthdate
School
Grade
Boy
Girl
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Health Conditions/Allergies: Add Health Condition: Comment: Add Health Condition: Comment: Add Health Condition: Comment:
Start Date: Start Date: Start Date:
In Case of Emergency: Names of persons who can assume temporary responsibility Name:
Relationship:
Home Phone:
Work Phone:
Cell Phone:
Medical Information Physician:
Physician's Phone:
Hospital Choice:
Hospital Phone:
Health Insurance: ● Medication given at school must be taken to the office in its original container. Generally a one day dose is recommended except where the prescription is long term. A form, which is available in the school office must be completed by the physician and placed on file in the school office. Medication taken at school must follow the guidelines as stated in the Student Rights and Responsibilities Handbook. ● In case of accident or serious illness, if the school is unable to contact me, my spouse or designated legal guardian, I hereby authorize the school to take my child to the physician named on this document. If it is impossible to contact this physician, the school may take my child to the hospital named on this document. If the school administration determines it would be in the best interest of my child's health and welfare, my permission is hereby given to use an ambulance. I hereby agree to all expenses incurred in the emergency case. ● I have read the current version of the Student Rights & Responsibilities Handbook, located at http://grandblanc.schoolfusion.us/ and understand it.
