New Student Enrollment Form Middle and High School

Student Enrollment Form - Whitehall, Montana 6-12

Previous School Name*

Answer Required

Previous School City & State*

Answer Required

Previous School Phone #*

Number Required

Previous School Fax #*

You may need to call your child's previous school for their fax #

Answer Required

Student's Legal First Name*

Answer Required

Student's Legal Middle Name

Answer Required

Student's Legal Last Name*

Answer Required

Student's Preferred Name

Answer Required

Student Cell Phone (if applicable)

Number Required

Date of Birth*

Answer Required

Place of Birth*

Answer Required

Race (check all that apply)*

Answer Required

Asian

Hispanic/Latino

American Indian/Alaska Native

Black/African American

Native Hawaiian/Pacific Islander

White/Caucasian

Other

Does your child have an IEP plan?*

Answer Required

Yes

Does your child have a 504 plan?*

Answer Required

Yes

Is your child's home language anything other than English?*

Answer Required

Yes

If yes, what language did your child learn when they first began to talk?

Answer Required

If yes, what language does your child most frequently speak at home?

Answer Required

Primary Household Information

Primary Home Phone*

Number Required

Physical Street Address*

Answer Required

City*

Answer Required

Zip/Postal*

Answer Required

Mailing Address (if different from physical address)

Street Address

Answer Required

City

Answer Required

Zip/Postal

Answer Required

Parent/Guardian Information

First Name*

Answer Required

Middle Name

Answer Required

Last Name*

Answer Required

Relationship*

Answer Required

Email*

Answer Required

Mobile Phone*

Number Required

Employer

Answer Required

Employer Phone

Number Required

Additional Parent/Guardian Information (if applicable)

First Name

Answer Required

Middle Name

Answer Required

Last Name

Answer Required

Relationship

Answer Required

Mobile Phone

Number Required

Employer

Answer Required

Employer Phone

Number Required

Siblings (Only list siblings also attending Whitehall Schools)

Sibling 1

First Name

Answer Required

Middle Name

Answer Required

Last Name

Answer Required

Age

Answer Required

Grade

Answer Required

School

Answer Required

Sibling 2

First Name

Answer Required

Middle Name

Answer Required

Age

Answer Required

Grade

Answer Required

School

Answer Required

Sibling 3

First Name

Answer Required

Middle Name

Answer Required

Last Name

Answer Required

Age

Answer Required

Grade

Answer Required

School

Answer Required

Additional siblings? List below.

Answer Required

Secondary Household/Members (Parent/Guardian NOT living in Primary Household)

Parent/Guardian Name

Answer Required

Relationship to Student?

Answer Required

Street Address

Answer Required

City

Answer Required

Zip/Postal

Answer Required

Emergency Contact Information

May be contacted in case of illness or emergency and must be able to pick up student.

Emergency Contact 1

First Name*

Answer Required

Last Name*

Answer Required

Relationship to Student*

Answer Required

Cell Phone*

Number Required

Home Phone*

Number Required

Answer Required

Work Phone

Number Required

Emergency Contact 2

First Name

Answer Required

Last Name

Answer Required

Relationship to Student

Answer Required

Cell Phone

Number Required

Home Phone

Number Required

Answer Required

Work Phone

Number Required

Student Specific Information

Court Protection Order?*

Answer Required

Yes

If yes, against who?

Answer Required

Parenting Plan?*

Answer Required

Yes

Medical Conditions (if applicable)

Answer Required

Medication taken at home?*

Answer Required

Yes

If yes, what and when?

Answer Required

Medication taken at school?*

Answer Required

Yes

If yes, what and when?

Answer Required

Does your child have any allergies that need to be noted?*

Answer Required

Yes

If yes, please list and describe allergies.

Answer Required

Has this student ever been suspended or expelled from school?*

Answer Required

Yes

If yes, please explain.

Answer Required

Is any individual named on this enrollment form (including parent, guardian, sibling, caretaker relative, emergency contact) currently or formerly a registered sex or violent offender?*

Answer Required

Yes

If yes, state name and their relationship to student.

Answer Required

Current or former individuals on the Sex/Violent Offender Reqistry are NOT permitted on school property or have limited access per District Policy #4015

I certify that I am the legal guardian of the child and that all information provided is true and accurate to the best of my knowledge. I verify that I reside within the school district boundaries or have an approved non-resident status for my child. If I do not reside within district boundaries, I will complete the required out-of-district paperwork and submit it to the school office within five (5) business days. My electronic signature also grants permission to request school records from any previous school my child has attended.*

Signature Required

Please fix the highlighted areas below before submitting.

New Student Enrollment Form Middle and High School