PERSHING COUNTY SCHOOL DISTRICT 
School Registration Form
STUDENT INFORMATION TO BE COMPLETED BY PARENT OR GUARDIAN

Last Name: ____________________________________  First Name:____________________________ Middle Initial: ____ 

Student Preferred Name_______________________________________________________

Student's Social Security #:________-____-________ Home Phone: _________________________  Birthdate:___________

Residence Address:__________________________________   Mailing Address:____________________________________
City:____________________________________State:_______________ Zip:_____________________

Gender:            Male             Female
Ethnic Group     Hispanic       White        Asian/Pacific Islander       African American    Native American 
Language Spoken in Home:	English	 Spanish           Other:

First Language Learned by Child:	            English	Spanish	    Other

	  Home Language Survey
aaMERI

 

INFORMATION OF STUDENT'S PARENTS OR GUARDIANS

Father                                                      

 

Last Name:_________________________ First Name:_______________  Status:    Natural       Step     Guardian
 Address:_____________________________________________________ Phone:___________________________
e-mail address_________________________________________________Father’s Cell: ______________________
Employer:____________________________________________ Employer's Phone:____________________________

MOTHER

Last Name:_________________________ First Name:_______________  Status:    Natural       Step     Guardian
 Address:_____________________________________________________ Phone:___________________________
e-mail address____________________________________________ Mother’s Cell:___________________________
Employer:____________________________________________ Employer's Phone:__________________________

EMERGENCY CONTACT 1 INFORMATION 

Last Name:_____________________	First Name:______________________ Relationship:________________________

Phone__________________________Cell Phone:___________________________ 

EMERGENCY CONTACT 2 INFORMATION
 
Last Name:_____________________	First Name:______________________ Relationship:________________________

Phone_______________________________Cell Phone:___________________________________

Parent Signature:_____________________________________________Date:_______________________________