Cement Public Schools

Enrollment

Enrollment form for the school year:

Student Information:

Last Name:

First Name:

Middle Name:

Physical Address

Mailing Address

Social Security Number

Grade

Sex

Reaquired field: Male

Reaquired field: Female

Date of Birth:

Place of Birth:

National Origin (check all that apply):

Reaquired field: Hispanic or Latino

Reaquired field: Not Hispanic or Latino

Reaquired field: Asian

Reaquired field: Black or African American

Reaquired field: White

Reaquired field: American Indian or Alaska Native

Reaquired field: Native Hawaiian or other Pacific Islander

Reaquired field: Other

Contact Information:

Father's Name

Father's Phone Number:

Father's email

Mother's Name:

Mother's Phone Number:

Mother's email:

Additional Emergency Contact Names and Numbers

Added Contact Name and Relationship

Added Contact Phone Number

Added Contact Name and Relationship

Added Contact Phone Number

eNote Notification System

If you answered yes to the above questions, please indicate which types of notifications you would like to receive (check all that apply):

Text

Telephone

eMail

Cell Phone Number for text notifications and phone calls

Additional cell phone number for text notifications and phone calls (if necessary):

Email address for email notifications:

Additional email address for email notifications (if necessary):

Special Conditions

Last school your child attended if different from Cement Public Schools

Was your child enrolled in Special Education?

Reaquired field: Yes

Reaquired field: No

Was your child enrolled in a 504 plan?

Reaquired field: Yes

Reaquired field: No

Was your child enrolled in a special math or reading class?

Reaquired field: Yes

Reaquired field: No

Was your child enrolled in speech, OT, or PT?

Reaquired field: Yes

Reaquired field: No

Each year we have vision screening tests administered by the Prevent Blindness organization, free of charge to students. Do you want your child to participate in these screenings?

Reaquired field: Yes

Reaquired field: No

Corporal Punishment

May the school administration use corporal punishment as a form of discipline on your child?

Reaquired field: Yes

Reaquired field: No

If you answered "Yes" to corporal punishment as a form of discipline, do you have any requirements or special conditions before it is administered?

Home Language Survey

If the following responses are something other than English, additional paperwork will be required.

What is the dominant language most often spoken by the student?

Reaquired field: English

Reaquired field: Spanish

Reaquired field: Other

What is the language routinely spoken in the home, regardless of the language spoken by the student

Reaquired field: English

Reaquired field: Spanish

Reaquired field: Other

Internet & Wireless Telecommunications Devices

Terms and conditions of Cement Public Schools Internet and Wireless Telecommunications Devices can be accessed on the school website and the student handbook.

I understand and will abide by the District's terms and conditions with regard to the Internet Access Conduct Agreement.

Reaquired field: Yes

Reaquired field: No

I understand and will abide by the District's terms and conditions with regard to the Wireless Telecommunication Devices Rules and Permission Form

Reaquired field: Yes

Reaquired field: No

Student Transportation

Will your child be riding the bus?

Reaquired field: Yes

Reaquired field: No

Where will your child be dropped off if other than your residence?

Emergency Medical Treatment Consent

Please list any health conditions such as heart disease, diabetes, epilepsy, severe allergies, eye or ear problems, or any chronic conditions that the school should be aware of:

Does your child take any type of medication that the school should be aware of?

Reaquired field: Yes

Reaquired field: No

If yes, please indicate the name of the medication, the time(s) the medication should be taken, and the dosage:

Your child's doctors name:

Your child's doctor's phone number (if known):

Authorization to Share Protected Health Information

I hereby authorize the Oklahoma Immunization Service to release my Immunization records and information located within the Oklahoma State Immunization Information System (OSIIS) to Cement Public Schools

Reaquired field: I authorize the release of my child's OSIIS information to ensure he/she meets Oklahoma eligibility requirements for schools.

Reaquired field: I do NOT authorize the release of my child's OSIIS information.

I understand that by voluntarily approving this authorization: 1) I authorize the use or disclosure of my Physical Health Information as above for the purposes listed, 2) I have the right to withdraw permission for the release of my information and revoke this authorization at any time in writing, 3) I have the right to receive a copy of this authorization, 4) I understand that unless the purpose of this authorization is to determine payment of a claim for benefits, signing this authorization will not affect my eligibility for benefits, treatment, enrollment, or payment of claims, 5) I understand I may change this authorization at any time in writing, however, I understand I cannot restrict information that may have already been shared based on this authorization, and 6) information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and may no longer be protected by HIPAA Privacy Regulations.

Authorization

Name of the parent or guardian completing this form and authorizing the enrollment of the above named child at Cement Public Schools for the indicated school year:

Date

Email a copy to

optional

Required Fields

CEMENT

PK-6 Website Enrollment Form