FARRELL AREA ELEMENTARY SCHOOL 1600 Roemer Blvd. Farrell, Pa 16121
PHONE: (724)-509-1114 FAX: (724)-509-1109 REGISTRATION FORM

Given to: ___Nurse
___ Special Ed.

STUDENT INFORMATION	Date:	

Student’s Legal Name ____________________________________________________________________________ Last	First	Middle
Street Address: _________________________________________ City __________________ ZIP Code __________

Mailing Address (if different from above): Postal Box: _________________ ZIP Code: ______________

Birthdate: _____/_____/_____	Sex:	Male	Female	Age: ________ Grade: ________

City/State of birth:______________________________________ State Entry (if not born in Pennsylvania): ___________

Race
	1-American Indian/Alaskan Native	3- Black or African American	5- White	9-Asian 10- Native Hawaiian/Other Pacific Islander	6- Multi Racial                    4-Hispanic

Does the student have an I.E.P/504 or have any special needs:__________

PARENT/GUARDIAN INFORMATION	Student resides with:	MOTHER	FATHER	GUARDIAN

Mother’s Name: _________________________________________________________________________________ First	Maiden Name	Current Last Name
Mother’s Birthplace : __________________________________ e-mail : ____________________________________ City	State
Phone number: (home)____________________________________(cell) ___________________________________

Father’s Name: __________________________________________________________________________________ First	Last Name
Father’s Birthplace : ___________________________________ e-mail : ____________________________________ City	State
Phone number: (home)____________________________________(cell) ____________________________________

Please indicate if the school administration should be aware of any Custody/Court Order related to your child.
____ Yes____ No	If ‘yes’, please make arrangements to discuss this situation with the school administration. Legal documentation will be required.

LAST SCHOOL ATTENDED

Name of School: ____________________________________________________________ Grade: ___________

Address: __________________________________________________________________ZIP Code: __________

Phone Number: ________________________________ Fax Number: ____________________________________

Dates attended: __________________________ Was the student ever enrolled in another PA school?	Yes	No

Has the student attended Farrell Schools previously?	Yes	No

OFFICE USE ONLY	Birth Certificate # ____________________ Grade: ____ Teacher: ___________________

Documents received:	___Immunization	___ Birth Certificate     ___ Proof of Residency