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Ekalaka Public Schools
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Student Enrollment Form

Student Enrollment Form
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Enrollment Date
required
Student Last name
required
Student First Name
required
Student Middle Name
required
Student Grade
required
Student Gender
required
Student Birthdate
required
Student Place of Birth
required
Student Ethnicity
required
American Indian/Alaskan Native
Asian
Black or African American
Native Hawaiian/Pacific Islander
White
Student physical address
required
Name and Address of School Last Attended
required
Grade level at School Last Attended
required
Transportation: Arrival
required
Car
Walk
Bus
Other
Transportation: Departure:
required
Car
Walk
Bus
Other
Migrant:
required
Yes
No
Foster Child:
required
Yes
No
Do you live more than 3 miles from school or the nearest bus stop? If so, how far?
required
Does the student have any physical problems that may affect school attendance?
required
List any special programs/services received at the previous school:
required
Family information
required

Please select the most applicable to your family.
Father and/or Mother
Legal Guardian
Father Information
required
Yes
NA
Mother information
required
Yes
NA
Father Last Name
required
Father First Name
required
Father Phone Number
required
Father Employer
required
Father Work Phone
Father Cell Phone
Father Physical Address
required
Father Mailing Address
required
Mother Physical Address
required
Mother Last Name
required
Mother First Name
required
Mother Phone Number
required
Mother Employer
required
Mother Work Phone
Mother Cell Phone
Mother Mailing Address
required
Legal Guardian: Last Name
required
Legal Guardian: First Name
required
Legal Guardian: Phone Number
required
Legal Guardian: Employer
required
Legal Guardian: Work Phone
Legal Guardian: Cell Phone
Legal Guardian: Physical Address
required
Legal Guardian: Mailing Address
required
Legal Guardian: Proof of Guardianship:
required
Court Order
Affidavit
Emergency Information: Medical Alert 1

i.e. Allergies, Asthma, Medical Conditions, etc.
Emergency Information: Medical Alert 2

i.e. Medications
Emergency Information: Medical Alert 3

i.e. Special Accommodations
Physician Name and Telephone Number
required
Hospital Preference
required
Any other Important Information:

Please remember to bring a Birth Certificate and Immunization records to the office!

Parent/Legal Guardian Signature
required
Draw your signature in the area above, or use the saved signature button if available.
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