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 ____
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Custodial Parent*(including joint custody) ___ One Natural/One Step-Parent*____ |
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Other (please explain) ________________________________________________
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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 ______________
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Home Phone __________________Work Phone_______________Cell Phone___________ |
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Contact #2 Name ___________________________________Relationship to Student ______________
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Home Phone __________________Work Phone_______________Cell Phone___________ |
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Contact #3 Name ___________________________________Relationship to Student ______________
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Home Phone __________________Work Phone_______________Cell Phone___________ |
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Contact #4 Name ___________________________________Relationship to Student ______________
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Home Phone __________________Work Phone_______________Cell Phone___________ |
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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 __________________________________________________________________