Wilson County Schools Registration Form
A student cannot be enrolled without the proper verification of custody, guardianship, and the establishment of legal residence in this school zone.
Student Last:                   First:                   Middle:                
Preferred Name:                 SS#:                   Sex: M   F   Grade:    
Date Enrolled:         Birth Date:         Birth Place:                              
Race of Student: Asian     Black     Hispanic     Native American     White     Hawaiian/Pacific  
Is English your child's primary language? Yes No What other language is spoken at home?            
Phone Number:                 E-mail Address:                                    
Address:                           City:               State:     Zip:          
Custody Both     Mother     Father     Joint     Other                          
If joint custody, who is the primary custodial parent?                                        
Mother:                   biological/adopted     step   foster     guardian     other    
Address:(if different from student)                                                    
Phone Numbers Home:               Cell:                 Pager:                
Employer:                                           Work Number:            
Father:                   biological/adopted     step   foster     guardian     other    
Address:(if different from student)                                                    
Phone Numbers Home:               Cell:                 Pager:                
Employer:                                           Work Number:            
Emergency Contact:                   Relationship:         Phone Number:            
Emergency Contact:                   Relationship:         Phone Number:            
Family Physician:                                       Phone Number:            
List any medical condition your child has that we need to be aware of.                              
Does your child take any prescribed medication?     Yes No If yes, a Wilson County Schools medical form must be  
filled out by a physician and on file before administering medication at school or before modifying normal school activities.
Please mark if your child has received any of the following.   Special Education     Title I       Speech    
When will your child ride the school b   A.M.   P.M.   Bus Number       Miles from home to school:    
Will your child ride a daycare van?   Yes No Daycare:               Phone Number:            
Others authorized to                                     Phone Number:            
pick up your child:                                       Phone Number:            
Persons NOT authorized to pick up your child:                                            
Last school attended:                         City:                   State:        
Is your child currently under discipline action from another school system? Yes No If yes, please explain and include
the name of the school system.                                                    
Other brother                           Age:                           Age:  
and sisters:                             Age:                           Ag    
In compliance with the issuance of free library books and textbooks, I agree to pay for the loss or damage to any books issued to my child.  I certify that all of the above information is true and correct.  I certify that I am the legal parent / custodian / guardian of the child identified on the registration form.  Upon change of residence or custody, I will notify the school office.
Parent/Custodian/Guardian Signature:                             Date:                
If you do not give permission for your address and phone number to be placed in the directory, please initial here.      
FOR OFFICE USE ONLY:   Proof of Residency     Birth Certificate     Custody Papers     Snow Letter    
Physical/Immunization Form     Records Requested   Fee Paid     Supply Charge $            
Received by:               Teacher:                                            
April 2002