EMIS# ___________________        Starting Date _________________ Bus # ___________Room # __________
Coming from ________________________________   
Receiving any Special Services  _________________________________
Former Student of Celina Schools ____________  
Former Student of Mercer Co. Head Start ________     Received Services for Preschool Handicap Program  ______
Has your child ever received Special Education Services? ________

CELINA CITY SCHOOLS ~ STUDENT REGISTRATION FORM
PLEASE CIRCLE BUILDING:        HIGH SCHOOL        MIDDLE        CIS        EAST        WEST

STUDENT NAME:
LAST_______________FIRST_______________MIDDLE__________NICKNAME -IF ANY)(___________)

STREET ____________________________________________________APARTMENT/LOT # ______________

CITY ________________________________________________ STATE_______________ ZIP _____________

HOME PHONE: 419 - _______ - ___________ BIRTH DATE: _____ - _____ - ____THIS YEAR’S GRADE ________

STUDENT’S SOCIAL SECURITY NUMBER : __________ - __________ - ___________           SEX: ________ (M or F)
RACE: _____  A=Asian-Pac. Isl.   B=Black Non Hisp.   H=Hispanic   I=Indian/Alaskan   M=Multiracial   W=White

BIRTHPLACE CITY __________________________ PARENT’S E-MAIL ADDRESS ________________________

FAMILY INFORMATION:
A. Student is living with:                                               B.  Student’s natural parents:                   C. Current home status:   
___both parents                  ___guardian                          ___both living                                             ___married
___mother                         ___relative                            ___father deceased                                        ___parents separated
___father                            ___foster parent                     ___mother deceased                                     ___parents divorced*
___step parent                     ___other

*Is there a court custody order pertaining to this child? ___Yes ___No

If so, who has custody? __________________________________(A copy of the custody order is required to be on file.)

PARENTS:
Legal Father’s First/Last Name and Address_________________________________________________

FATHER’S PLACE OF EMPLOYMENT: __________________PHONE______EXT. _____CITY ____________

Legal Mother’s First/Last Name and Address____________________________________________________________

MOTHER’S MAIDEN NAME  _____________________________

MOTHER’S PLACE OF EMPLOYMENT: __________________PHONE______EXT._____CITY_____________

Student’s Guardian First/Last Name and Address _________________________________________________________

GUARDIAN’S PLACE OF EMPLOYMENT: _________________PHONE______EXT. _____CITY____________

OTHER CHILDREN IN HOUSEHOLD
Name:                                    Sex:         Age        Grade                   Name:                               Sex:      Age     Grade
__________________________   ___         ____       ____                   ______________________   ___       ____   ____

__________________________   ___         ____       ____                   ______________________   ___       ____   ____
IF YOU ARE UNABLE TO COME TO SCHOOL AND GET YOUR CHILD IN CASE OF INJURY OR ILLNESS,
PLEASE LIST NAMES AND TELEPHONE NUMBERS OF PEOPLE WHO WILL SUBSTITUTE FOR YOU. 
PLEASE CONTACT NEIGHBORS AND/OR RELATIVES WHO HAVE TELEPHONES.  IT IS VERY IMPORTANT
THAT WE HAVE COMPLETE AND ACCURATE INFORMATION.  THANK YOU!

NAME: __________________________RELATION: _______________ PHONE: _____________________________

NAME: __________________________RELATION: _______________ PHONE: _____________________________