Online Registation Form K-6 | Glacial Hills Elementary

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Student Last Name*

Student Middle Name*

Student First Name*

Student Gender*

Student Birthday*

Month

Day

Year

Entering Grade Level*

If entering PreSchool/PreKindergarten, please select one:

Please only answer this if your student is entering PreSchool or PreKindergarten.

Enrollment Start Date*

Ethnic and Racial Demographics required by Minnesota Department of Education. Is the student:*

Hispanic or Latino as defined by the Federal Government.

American Indian or Alaskan Native as defined by the Federal Government.

Asian as defined by the Federal Government.

Black or African American as defined by the Federal Government.

Native Hawaiian or Pacific Islander as defined by the Federal Government.

American Indian from South or Central Amercia as defined by the Federal Government.

Caucasian/White as defined by the Federal Government.

Parent/Guardian 1 Name*

Parent 1 address*

Parent 1 address 2*

Parent 1 address 3*

Parent/Guardian 1 Cell Phone*

Parent/Guardian 1 Email Address*

Parent/Guardian 2 Name

Parent 2 address

Parent 2 address 3*

Parent/Guardian 2 Cell Phone

Parent/Guardian 2 E-mail address

Student lives with:*

Student's Previous School

Student has IEP in place

Please only fill out if known.

Emergency Contact #1*

Emergency Contact #2*

Non-Aspirin (Acetaminophen/Tylenol or Ibuprofen) medication will be provided when necessary and only in the case of a low-grade fever.

According to school policy, administration of ANY medication (prescription or over-the-counter) must be requested by written permission from the parent or guardian.

Has your child had any complaints of or treatment for any of the following?

Pollen/Hay Fever

Bee Stings

Food

Animal(s)

Diabetes

Glasses/Contacts

Hearing Loss

Skin Conditions

Seizures

Behavioral

Other

Signature*

Please fill out the Multiple Permission Form next.

(320) 244-3334

610 W 6th St, Starbuck, MN 56381, USA

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