Margaret Daniel Primary Student Information Sheet              
Date:_______________________         Teacher:____________________        
Please Print:                            
Student Social Security Number:____________________________________ (Optional)              
                             
Student First Name:______________________ Middle:______________________ Last:______________________          
(circle preferred name)                          
M/F:________ Birthday: ___________________________      Race:_________ Grade:_____________________          
                             
911 Address:___________________________________________________________________________________        
                             
City:______________________________ State:______________ Zip Code:___________ County:___________________          
                             
Mailing Address (if different) __________________________________________________________________          
                             
Home Phone:______________________ Listed or Unlisted   Cell Phone:__________________________          
Parent/Guardian: E-Mail Address   _________________________________________________            
                             
Race/Ethnicity Two-Part Question: Answer BOTH questions.                    
1.  Is this student Hispanic or Latino?  (choose only one)                    
_____ No, not Hispanic or Latino                        
_____ Yes, Hispanic or Latino ( A person of Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish           
culture or origin, regardless of race.                      
2.  What is the student's race?  (Regardless of how first question was answered, choose one or more)              
_____American Indian or Alaska Native (a person having origins in any of the original peoples of North and South           
America, including Central America, And who maintains tribal affiliation or community attachment.)             
_____ Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian                                                                                                                             
subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands,         
Thailand, and Vietnam.)                        
_____ Black or African American (A person having origins in any of the black racial groups of Africa.            
_____Native Hawaiian or Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa,        
or other Pacific Islands.)                        
_____White ( A person having origins in any of the original peoples of Europe, the  Middle east, or North Africa.)          
Status:                            
Student lives with: (Circle one)       Student Guardian: (Circle one)          
D.     Father & Stepmother      L.   Legal Guardian     1.     Both parents            
E.     Mother & Stepfather M.  Mother only     2.     Father              
F.     Father only   P.    Living with both parents   3.     Mother            
G.     Grandparents   T.  Foster Parents     4.     Guardian            
H.  Homeless           5.     Emancipated Minor          
                             
Parent/Guardian Information (That student lives with)                    
Father's Name:_______________________________________________                
Father's Employer:____________________________________________ Work Phone:_________________________          
Mother's Name:______________________________________________                
Mother's Employer:___________________________________________ Work Phone:_________________________          
Travel and Birth Information:                        
How will your child get to school?  (Circle one): G-Parent/Guardian D-Drives self              
        B-Bus   P-District Paid Transportation            
How many miles do you live from school?  _________ City/State of Birth:______________________________          
Emergency Information:                          
List two (2) nearby relatives or neighbors we can contact if we are unable to reach you.              
Name:______________________________________________________ Relationship:_________________________          
Home Phone:______________________________ Cell/other:______________________________________________        
Name:______________________________________________________ Relationship:_________________________          
Home Phone:______________________________ Cell/other:______________________________________________        
I, the undersigned, authorize the school to take necessary action for the protection of my child in an emergency.          
__________________________________________________________ Date:______________________________          
Signature of parent/guardian                        

 

HOME LANGUAGE/PRE-SCHOOL SURVEY

Student’s Name__________________________________Teacher____________________

What Language is spoken in your home most of the time?__________________________

Student’s Language___________________ Parent’s Language ______________________

 

Check As Many As Apply:

______Regular Education Student

______504 Student   

______Speech Therapy

______Special Education (if checked) Student-Medicaid Number____________________

______Occupational Therapy       _______Physical Therapy              ______ESL

______ Migrant                    _______Homeless                ______Gifted & Talented

 

Has student ever been retained? _______ What grade/year?________________________

 

 

Pre-School program attended before entering Kindergarten.

 

List any pre-school programs your child attended: Examples: ABC, Head Start,

Private Day Care

 

_______________________________________________________________

 

My child attended a pre-school program:  (Please check one)

________20 hours or more per week      ________Less than 20 hours per week

 

________My child did not attend a pre-school program

 

 

** Below for New Students to the Ashdown School District Only

 

Discipline Information:  ACT 472

Have you been expelled or were you about to be a party to an expulsion proceeding? ____Yes    ____No

If yes, please explain_________________________________________________________________

 

Have you previously attended/or been referred to an Alternative Learning Environment? ____Yes  ____No

If yes, please  explain:_____________________________________________________________________________

 

Were you in/or being sent to ISS (In School Suspension) in your other school? _____Yes             _____No

If yes, please explain:________________________________________________________________________

 

School Attended Before This One:

 

School ____________________________    City__________  State_______