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Teacher’s Name ________________________________________ AM Bus # ________ / PM Bus # __________ 2012-2013 MARION SCHOOL DISTRICT ENROLLMENT FORM
MARION ELEMENTARY SCHOOL – Grades 2-3
WARNING: Any person who knowingly gives a false residential address for the purpose of public school enrollment is guilty of a
misdemeanor and subject to a fine not to exceed $1000. (A.C.A. 6-18-202) The Marion School District will prosecute those who present
false addresses.
GENERAL STUDENT INFORMATION
First Name: ______________________________ Middle Name: ________________________________ Last Name: __________________________
SSN: ______________________________ Grade: ________ Birthdate: ________________ Age: ___________ Gender: M or F
Physical Address where child lives:
Street: ________________________________________________ City ____________________________ State _____________ Zip ________

Ethnicity (check one):
Primary Race (check only one):
Additional Race (check all that apply):
Primary Language spoken in home:

Method of Transportation (check all that apply):
_____ Parent/Guardian (includes walkers, child care vans, etc.) • My child wil ride the bus to school in the morning from: ____________________________________________________________________ • My child wil ride the bus from school in the afternoon to: ___________________________________________________________________ Last School Attended: ____________________________________________________________________________________________________
Address: ___________________________ City: ___________________________________ State: __________ Zip Code: _____________ GUARDIAN INFORMATION
Living With: (check one)
Guardian Address Information: Guardian #1 will be the primary guardian and will be called first in the event of an emergency.

Guardian #1
___________________________________________________ _____________________________________________ Relationship to Student: _______________________________________
Relationship to Student __________________________________ Mailing Address: _____________________________________________
Mailing Address: ________________________________________ ___________________________________________________ _____________________________________________ State: _______________
Zip Code: ____________________
Phone: ___________________________________________________
Phone: _____________________________________________ Guardian #1 Workplace: _______________________________________ Employer: _________________________________________________ Employer: _____________________________________________ Work Phone: _______________________________________________ Work Phone: ___________________________________________ Guardian #1 email address: _____________________________________ Guardian #2 email address: ________________________________ EMERGENCY CONTACT INFORMATION
Emergency Contact Information:
Contact 1 Name: ____________________________________________ Contact 2 Name: ________________________________________ Contact 1 Phone: ___________________________________________ Contact 2 Phone: _______________________________________ Has this child been expelled from school in any other school district or is the child a party to an expulsion proceeding: _____Yes _____No • Has this child been involved in a divorce in any way? **If yes, we must have certified copies of the most current court order (with judges signature) in our school files. • Are custody procedures now in progress? **If yes, we must have a copy of the temporary orders at this time, and a certified copy of the final custody papers when custody is GENERAL MEDICAL INFORMATION
Does your child have one or more of the fol owing disabilities? (please check any that apply) _______ Autism
Medical History: Does your child have now or ever had any of the fol owing: (please check any that apply)
_______ * Al ergies
*Please identify any al ergies or chronic il nesses. _________________________________________________________________________ There is a physician’s care plan on file with the school for the condition listed above. _____Yes _____No Please list any other medical concern for this child: ____________________________________________________________________________ ______________________________________________________________________________________________________________________ Medications that your child takes regularly:
Name of medication: _________________________________________ Dosage: ___________________________________________ Name of medication: _________________________________________ Dosage: ___________________________________________ NOTE: If your child will take medicine at school, you must complete a medication administration release form in the office. All medications must
be administered through the office.
ADDITIONAL INFORMATION
If your child wil go to a day care center or baby sitter after school, please provide the fol owing information. Name/Daycare: __________________________________________________________________ Address: ________________________________________________________________________ Phone #: ________________________________________________________________________ Names and ages of brothers and sisters in the home: _______________________________________ ___________ ______________________________________ ___________ _______________________________________ ___________ ______________________________________ ___________ _______________________________________ ___________ ______________________________________ ___________ _______________________________________ ___________ ______________________________________ ___________ PARENT PERMISSIONS
Authorization for Medical Treatment:
If parent, guardian, or person designated cannot be reached, Marion School District has authority to give consent for emergency medical treatment. The school district is in no way financial y responsible for medical treatment. Parent’s or guardian’s signature indicates permission for the school nurse or principal of the school to fol ow the directions above. Permission is also given for any child to take acetaminophen (Tylenol) in case of fever, headache, etc. Tylenol wil only be given if the child’s temp is 103 degrees and parent cannot be reached. Field Trip Permission:
I give my permission for my child to go on any field trip related to school activities. I hereby waive and release the school from any and al possible claims for injury to person or property which might arise in connection with my child’s participation in these activities. My child is in good physical condition and has had no serious il ness or operation since his/her last health examination. I wil notify my child’s teacher of any health condition that might need to be monitored on any field trip. Permission to use name/picture:
I give permission for my child’s name and/or picture (either as an individual or as part of a group) to appear in articles relating to school in school newsletters, on the school website, and/or in area newspapers. Authorization to pick up child from school:
The fol owing people have permission to pick up my child from school. I wil cal or write a note if one of these persons wil pick up my child, or if there is any change in the usual way he/she goes home from school. I understand that only the people listed below wil be al owed to pick up my child. Name ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ _______________________________________________________ Parent/Guardian Signature

Source: http://www.msd3.biz/rwd/faculty/j_cook/docs/MESEnroll.pdf