Please continue to the other side OVER

Date

Legal Last Name: Legal First Name: Middle Name Preferred Name at School

Date of Birth Is the student Hispanic/Latino or of Spanish origin?

Yes No

Ethnicity (choose one or more of the following)White Am Indian/ Asian

Alaska NativeBlack Pacific Islander

Has your child ever attended Tonganoxie

StudentCell Number: ( ) -

schools before? Yes NoGender Grade

/ /District Resident Yes No

Is a language other than Standard American English used in the home? Yes No If yes, what language?

¿Se utiliza otro idioma en el hogar aparte del Inglés? Si No Sí sí, ¿qué idioma?What is the student’s primary language? ¿Cual es el primer lenguaje del estudiante?

PARENT/SIBLING INFORMATIONFather’s Name (As Shown on Drivers Licence) Place of Employment Step-Mother’s Name (if applicable) Place of Employment

Home Phone Father’s Work Phone Cell Phone Step Mother’s Phone (if applicable)

Address City, State, Zip Father’s Email

Mother’s Name (As Shown on Drivers Licence) Place of Employment Step-Father’s Name (if applicable) Place of Employment

Home Phone Mother’s Work Phone Cell Phone Step-Father’s Phone (if applicable)

Address City, State, Zip Mother’s Email

Student Resides With: Email to be used for school correspondence:Father’s Mother’s

Who has custody? (Please explain)

Father’s Driver Licence Number: Mother’s Driver Licence Number: Is Student in Foster Care

IN CASE OF EMERGENCY– for when student is in district facilitiesUnless you indicate otherwise, we will attempt to call mother/father first at home on their cell, then at work. List any relatives, friends, or neighbors who wouldassume temporary care of your child if they are ill and/or need to be picked up from school and youcannot be reached. Please list in order.1. Name Relationship Phone

2. Name Relationship Phone

3. Name Relationship Phone

4. Name Relationship Phone

May the non-residenital parent and the school have contact? Yes No(If no, we must have a court order to enforce this)

May the non-residential parent pick up the student from school at any time?

Yes No

Brothers and Sisters (Names and Ages)

Yes No

Father/GuardianActive Duty

MilitaryReserve

Mother/Guardian Active DutyMilitary Reserve

STUDENT INFORMATIONDistrict Enrollment Form 2021-2022

PERMISSIONSI give permission for my student to use school computers/Digital Citizenship, including Internet, under the supervision

I give permission for my student to attend trips planned by the school and under the supervision of school personnel.I give permission for my student’s photographs, videotape coverage, voice,

I give permission for my students to participate in Surveys. (TMS & THS only)

yearbook, and/or student workand/or grades (including honor roll and other academic achievement awards) to be used in school- related

I have been provided with notice of authorized student data disclosures under the Student Data Privacy Act. I consent to the district disclosing data concerning my students which is submitted to or maintained in a statewide longitudinal database and which is defined as directory information under the Student Data Privacy Act as necessary. If I choose to revoke my consent, I recognize that I may do so at any time by putting such request in writing and submitting it to The Superintendent at Tonganoxie USD 464, 330 E. HWY 24-40, Tonganoxie, KS 66086.

Signature

Please complete the portion below if you are enrolling your student in this school for the first time, or if they have attended any other school since attending here.

Name and address of school last attended:

How long has your child attended school in the US? (only if coming from out of the country) ¿Que tanto tiempo hace que su hijo/a a asistida a la escuale en los Estados Unidos? Please check any special classes your child was in at the previous school:

Reading Math Learning Disabilities Speech Gifted OtherOther items you would like us to be aware of: Does the student have an IEP?

Yes No

HEALTH INFORMATIONDoctor’s Name

Doctor’s Phone Number

Hospital

Signature of Parent of Guardian

MEDICAL HISTORYList Allergies Diseases, Operation, Injuries (give dates) Medical Considerations Requires Special Services (Explain)

PLEASE CHECK WHETHER YOUR CHILD HAS /USES THE FOLLOWING:Yes No Yes No

Visual or Hearing Problems Wears corrective lensesVent tubes Frequent ear infectionsWears hearing aids

MEDICATIONSYes No

Medication at HOME If yes, name of medicine(s)

Medication at SCHOOL If yes, name of medicine(s)

Yes No

Yes NoYes No

Yes No

Yes No

publications/website or promotional pieces.

My student has read and will abide by the Bullying Prevention Guidelines. Yes Noof school personnel.

The Tonganoxie Public Schools, Unified School District No. 464 is committed to maintaining a learning and working environment free from discriminatory behavior in the form of insult, intimidation, or harassment due to race, color, religion, sex, age, national origin or disability. Harassment of students or employees of the district by any person is prohibited. Students or employees who believe they have been subjected to harassment on the basis of discrimination should discuss the alleged harassment with the building compliance coordinator and/or principal, the guidance counselor, or another certified staff member. Any school employee who receives a complaint of harassment from a student must report the complaint to the compliance coordinator and/or principal. The following individuals have been designated the compliance coordinators for their building: District Compliance, Superintendent of Schools 330 E. Hwy 24/40, Tonganoxie, KS 66086, (913) 416-1400.