Student Registration Form

Custom Form


Covington City Public Schools

Student Registration Information

Please answer all questions. If any of your information changes during the year, please call the school office or send a note to school to update information. Thank you.

Student Name:
Last Name First Name  Middle Name 

    Grade  

Mailing Address  City  State  Zip 

Phone  Social Security #  Date of Birth 

Residence:  

Parent/Guardian InfoParent #1Parent #2
Parent/Guardian Name
Home Address
Home Phone Number
Employer
Work Phone Number
Cell/Pager Number
E-mail Address
1st number to call during school hours
Military InformationActive Duty 

National Guard or Reserves 

Active Duty 

National Guard or Reserves 

 

Names of brothers/sistersAgeGradeReside in same home as student? Yes/No

Emergency Contact:  List persons authorized to pick up your child from school and/or may be contacted in case of illness or emergency.
School staff will attempt to contact parent/guardian first. 

NameRelationshipPhone

Please list individuals who are NOT AUTHORIZED  (but may attempt) to pick up your child.


Special Services Received at Previous School (please choose all that apply)


Special Education 504 Plan Speech  Gifted/Talented  Reading  Title 1  English as a Second Language


Medical Information:
Physicians Name:  Telephone#: 

Health Alerts and information: (ex: diabetes, allergic reactions, etc)

Your child has the following health insurance (check all that apply) Private Medicaid FAMIS None


Custody Information: Complete only if parents are separated or divorced. Custody arrangements (check one):
Joint legal & physical  Joint legal with physical custody retained by Mother  Father
Sole legal & physical custody  No formal custody arrangements  Lives independently
Provide all legal documents regarding custody & visitation.


Birth Information:
Birth City:  Birth State:   Birth Country: 

Ethnicity: (choose only one)
No, not Hispanic or Latino
Yes, Hispanic or Latino 
A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish Culture or origin, regardless of race. 

Race(must choose at least one, may choose one or more; see information below for race definitions)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian/Other Pacific Islander
White
Race Definitions
American Indian or Alaska Native:
A person having origins in any of the orginal 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/Other Pacific Islander: A person having origins in any of the orginal 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 America.


Home Language Survey:
What date did the student enter School in the United States? (enter numbers) Month  Date  Year 
What is the primary language used in the home, regardless of the language spoken by the student? 
What is the language most often spoken by the student? 
What is the language that the student first acquired? 
What language(s) do adults speak at home? 
Has the student ever received ESL (English as a Second Language) services? Yes  No


Living Situation Complete only if student lives in any of the below locations/situations. Check the appropriate box.
Shelter  motel/hotel, campground or similar setting  car  public building or space  awaiting foster care
living with another family due to loss of housing or economic hardship


Previous School History: Has student previously attended Covington City Schools? Yes  No
Most recent school attended if other than Covington City Public Schools? 
School Name: 

Address: 

Ending date of attendance: 


Transportation:  How will your child get to and from school each day? 
School bus a.m. p.m.  Car a.m.  p.m.  Walk  a.m.  p.m.

AM bus pick-up; specific street address: 

PM bus drop-off; specific street address: 


REGISTRATION FORM STATEMENT

I hearby swear and affirm that the student named on the front of this form has not been expelled from school attendance at a private school or in a public school division of the Commonwealth or another state for an offense or violation of school board policies relating to weapons, alcohol or drugs, or for the willful infliction of injury to another person. I understand that any person making a materially false statement or affirmation shall be guilty upon conviction of a Class 3 misdemeanor. 

Parent/Guardian:       Date: 
 

 

 



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