THE SCHOOL DISTRICT OF PALM BEACH COUNTY (SDPBC)

THE SCHOOL DISTRICT OF PALM BEACH COUNTY (SDPBC) New and Returning Student Registration NEW STUDENTS: Complete all non-shaded areas 011 both sides of the form. RETURNING STUDENTS: Review botlisides. If the pre-printed information is 'nconect, correct the Information by carefully and lightly crossing out the Incorrect Information and writing the correct information above It. (3) (4) (7) seem sECuerry NO. (0) NOME TELEPHONE NO (9)SEX POI FEAWETHNIE MON IFPFGAIN askan Native 0 E lacic. Non-Hispanic 0 H-Hispanic der 5f etWhite, Non.HIsparde 0 M-Muldracial OM mow STATUS 0 O. Foreign Exchange Student 01. Out-of-county Resident 0 2. Out-of-state Resident 04. In-county Resident (14) USA array DATE pmecovren YES NO LI 0 A. The student resides on federal property. 0 0 B. The student resides in low rent houskrg. Di 0 c. The parent le employed on federal property leaded in Palm Bead) Catty. 0 0 D. The parent is employed on low rent housing located in Palm Beach County 0 0 E. The parent is in the uniformed services of United States. (iti)eRISCH001. MOUND° iNfoRuAnoei Pigtail Xby eachprogram attendee Also. Indicate with at asterisk C) thegogreen your MO was in the lode!. 0 N. Non-subsidized Child Care 0 M. Migrant Pre-K 0 D. Pre-K Disabilities . El H. Headstart 0 t. PreK Early Intervention 0 C. Chapter I 0 S. Substdaed ChId Care 0 O. other. O 0 If E. Is YES, is the meant on active duty? Check service below: • • 0 Air Force U Army 0 Coast Guard 0 Marries 0 National Guard 0 Navy STUDEN A (Intialle T Mae O 0 YESIW 00)CURRENT GRADE LEVEL 8 frir sy ( h9) tome OF Snort. TRANSFERRING 'ROW 120 OTY OR LOCATE:el PiOniee t / I ll b ede 54 #3° Z• Cps" pelt, r 1 ne4. all/AST A 4.)M4CE On7E et 6 ..) 6 6 i tal LAST GRADE LEVEL PILAW PUBUC SCHOOL ATTENDED ,i4 PALM BEACH001AM WI DATE Annaba IN Mac MESVOStni(i gs) Students will receive non-invasive health screenings pursuant to Florida Statute § 381.0056{7)(d). Noninvasive May in it . screerings may include vision, hearing. scrims's, height, arid weight. These tests be given individually or groups. Parents or guardans, however, have the right to request an exemption In writing. If you DO NOT want your chord to receive the-screenings, write the words 'Do not weed' here: 12) i Have p 4 oj rr free an and re ducedd lunch? (This exemption wit cover all types of screenings) cm I give permission for my child to participate in the sodium flouride program to prevent tooth decallg4S0 NO (Permission is valid through 6 grade) OYES RiTC (Application is pibv,decl wilts this ban) !tat NOME LANGE:AGE Waver YES NO o Is a language othfc than English used in the home? If YES, what language? j 0 ce .' 2. Does Me student have a first language other than English? II YES, what language? U el. "-Does the student most frequently speak a Language other than English? If YES, what language? (29) 4. What language is spoken in the home by the parent or guerilla/1? ..0O/.54 (30) 5. What language Is the student's first language? rniii‘ri/S4 ni) What is the date of entry Into an ESOL program? (72) Myr INESWITIC —and' tr filother 0 Father 0 Both Parents 2( )ltior oilziot-bPsikeors (33)CesCLOSuliEs Pa&MYINTOPee SCHOOL DtSTRICT YES NO, 0 _A. Has the student ever been expelled from school? 0 .M ).. Has the student ever had an arrest restAting Ina charge? CI w?. Has the student ever had any juvenile justice actions? (SO CIATOOY STATUS Of SluDIEFIT peek** 0 Mother 0 Father PShared Custody 0 Other PM le there a court order leaning either parent from removing or contacting the student during the school del? DYES. provide the school with a copy of the court order. RS.500636 (REV. 4162001) CONFIDENTIAL page 1 402 MM08-A HALL-000008 3501.103-025 Page 1 of 2 EFTA_00063113 EFTA01246249 THE SCHOOL DISTRICT OF PALM BEACH COUNTY • NEW AND RETURNING STUDENT REGISTRATION po MINER OR LEW& GUAROWI 0591. Sloe PISA PIO AO0FtESS (andir aanM. ant pwmanrnunte, CITY STATE 20/ COOS , OCCUPATCH . [repeated 3 times] PUCE 00 EMPLOYIAEN NOME TRUMP* BLISNESS TELEPHONE CELUPAGER NUPOER EMAIL ADORESS profewI "WeTilleVitisakliA6 tram - F`'' 9... ' aarVagii vaaM sainciiiit#:‘: Person(s) other than parent authorized to pick up student (PS) PASSWORD (P'T.2 Mc/Waders) (39) NAPE (t21 I>Nt WO 40 NAME (tit. aJ.V.in4lt ANS Sr.. UN( I (Mon . Abetlinealbabf4 STATE ZIP COOS I I RIBA • 1 (4dI 2)AUNORG!E0 FOR 0 YES 0 NO (0) II school parsOnnel are unable to contact you incase of Plness or accident, (44) ICDCAL INFORMATON alsiption Mona tfliGr. talk swain. intdadrescntaleroteekerfrisatIree may we have your permission to call your doctor-dr. . H•' . _ emergency seivices (9 1) for transportto the teseitan efii 0 NO . „rnhies (46)FAWLY PHYSICIAN nmedda, (46)PHYSCAN RHONE isv on Does your child rummy have ht. health Insurance? BIES 0 NO EYES. indicate: 47) HOSMT AL PREFERENCE 0 Medicaid likgate o Healthy Kids/Kid Care 0 Interested ki receiving information , .ITMailpi iriilijal!r-a: ite .. ".' (It NAME OF CHILD gut fat med. 1400 501004. ATTENDIVG CMOS BIRTH 00) NAME OF CIAO (Pst test med. M40 SCHOOL ATTEMINO DATE OF BRIM (SI) NOW OF MILO (kIt oat 49no P490 : 50400. AT1134DINO SWUM NO. foOkNQ WIN:* DATE Of BIRTH '... (SOMME OFCHILD east Fat. °Akio MOO SCHOCC. ATTENC*90 STUDENT NO. Rollos* WADE DATEWORN PARENT/GUARDIAN SIGNATURE 0.0,10VV. I verify that the information given is true and accurate to the best of my knowledge. • • stiii4o_Ta *NUE ;?*" -.7.. - r' c.3,/ "qts'-c-" -Wiehr - :2, ;I. .-. c —,-- - P -7. ,,,, . • . • .;•,c.1: -A,. nnen (tale Ion, A IC PM! ill CONFIDENTIAL Page 2 of 2 EFTA_00063114 EFTA01246250