Registration Form

OGDEN CITY SCHOOL DISTRICT STUDENT REGISTRATION FORM

Student’s Last Name: First Name: Middle:

Grade: Sex: M F Date of Birth: SS#:

Has child attended Ogden City Schools before? Yes No School he/she last attended:

Are you Hispanic/Latino? Yes No   Please select one or more of the following races for yourself:

Amer. Indian/Alaska Native Asian Black or African Amer. Native Hawaiian or Other Pacific Islander White

If American Indian, please check one: Goshute Navajo Paiute Northwest Band Shoshone Ute Other

In what country was student born (If USA, leave blank): Date entered U.S.:

Home Address: City/State: Zip:

Mailing Address (if different): City/State: Zip:

Home Phone: Does your child require Special Education services? Yes No 504 Plan? Yes No Other?

Father’s Last Name: First Name: Lives w/child? Yes No

Home Address: City/State: Zip:

Mailing Address (if different): City/State: Zip:

Home Phone: Cell Phone: Email:

Work Address: Work Phone: Occupation:

Mother’s Last Name: First Name: Lives w/child? Yes No

Home Address: City/State: Zip:

Mailing Address (if different): City/State: Zip:

Home Phone: Cell Phone: Email:

Work Address: Work Phone: Occupation:

Legal Guardian (if other than parent listed above):

Last Name: First Name: Lives w/child? Yes No

Please indicate relationship to child (check one listed below):

Stepfather Stepmother Sibling Court Appointed Guardian Uncle/Aunt Grandparent Relative Other

Home Address: City/State: Zip:

Mailing Address (if different): City/State: Zip:

Home Phone: Cell Phone: Email:

Work Address: Work Phone: Occupation:

Emergency Contacts other than parent. Please provide at least one emergency contact.

1) Last Name: First Name:

Address: Home Phone #: Work Phone #:

Relationship: Stepfather Stepmother Sibling Uncle/Aunt Grandparent Relative Friend/Neighbor Other

2) Last Name: First Name:

Address: Home Phone #: Work Phone #:

Relationship: Stepfather Stepmother Sibling Uncle/Aunt Grandparent Relative Friend/Neighbor Other

Other persons authorized to check my child out of school:

Daycare authorized to pick up my child: Phone:

Unless authorized by the custodial parent in person, the child will not be released to anyone other than parents and persons listed on this page. You may change emergency contacts by coming to the school.

Please mark any of the following that may apply. This information helps the district determine if the student is eligible for additional services.

ZH1. Lives with another family because of a loss of housing or economic hardship.

ZH2. Lives in a motel or hotel.

ZH3. Lives in a shelter (emergency, transitional, or domestic violence).

ZH4. Lives in a car, park, campground, or public place.

ZH5. Lives in a residence without adequate facilities (running water, electricity, heat, etc.).

ZH6. Seeks enrollment without accompanying parent (not to include youths in foster care).

Has the student's family moved to seek agricultural work in the last 3 years? Yes No

Health Information:

Glasses/contacts: Hearing Aid: Physical Problems: Daily Medicine:

Health Problems:

Required assistance: Transportation: Wheelchair: Adult Assistance: Special Equipment:

In case of an ACCIDENT or SERIOUS ILLNESS, I request the school to take whatever action seems appropriate.

Please list other children in your family (18 years or younger):

Name    Gender    Age    Birth Date    School Currently Attending

Frequently, Ogden City School District and the media wish to feature student achievement, extra curricular activities, clubs, sports, and other activities. Do you give permission for your student’s name, picture, school, age, and any honors received or activities participated in to be utilized in school or district publications, yearbook, school directory, news media, and other publications? Yes No

I certify that I am the legal guardian or custodial parent of this student. I certify that I have read and understood the information on this registration form, that the information entered is correct, and that I will notify the school of any changes to the information herein.

The district is requesting this information to better serve the needs of our students under the authority of PL 94-142, Title IV of the Civil Rights Law and State Administrative Rule R227-716 (1 to 5). This information will be handled confidentially and will be used only for purposes noted in the law or rule. This information will not subject you to unfair or discriminatory treatment.

For School Use Only

Special Programs: Special Education: 504:

Is student eligible for busing? Yes No Lives within 1 1/2 miles More than 1 1/2 miles Pickup Bus #: Dropoff Bus #:

Fee Waiver requested: Yes No Lunch Qualification: Free Reduced Paid Immunizations Record: Yes No

Exemption registered: Yes No Emergency Immigrant: Refugee: Homeless: Student is PHLOTE: Yes No

Date referred for English Language Proficiency testing: Principal’s signature:

• This information is recorded on SIS under: Services/Programs, Program History, Find, Student, and Add. • Select ZH code from pull-down box, and click OK • Enter entry date (if date is not known use their registration date) • Enter Status (must be active) • Leave all remaining boxes blank • Click save