Enrollment Date
/
Month
/
Day
Year
Date
Grade
Birth Date
/
Month
/
Day
Year
Date
Sex
Male
Female
Name of Student
Address
Child lives with
Students SSN
Place of Birth
I give consent for LeFlore Public Schools to have my child tested for Gifted and Talented?
Yes
No
Where is the student currently living? (Please check one box.)
In a shelter.
With another family member due to loss of housing.
In a hotel/motel.
In a car, park, bus, or campsite.
Permanent housing.
Other
FatherGuardian
Place of Employment
Work Phone
Format: (000) 000-0000.
Cell
Authorized to pick up.
Yes
No
MotherGuardian
Place of Employment
Work Phone
Format: (000) 000-0000.
Cell
Authorized to pick up.
Yes
No
Emergency Contact Person other than parents Name
Phone
Format: (000) 000-0000.
Other persons authorized to pick up your child:
Name
Phone
Format: (000) 000-0000.
Name
Phone
Format: (000) 000-0000.
Name
Phone
Format: (000) 000-0000.
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