Returning Student Application

Date *

Date

What grade will your child be entering this school year?*

Last Name*

First Name *

Middle Name

Social Security Number*

Address*

Address

Street Address Line 2

City

Zip Code

Race*

Date of Birth*

Place of Birth*

Gender

Mailing address if different from above

Bus Number (if known)

Driver (if known)

Only complete this section if there are any changes to your information.

Mother/Guardian Name

Phone number

Place of Employment

Phone number

Mothers Email required

example@example.com

Father/Guardian Name

Phone number

Place of Employment

Phone number

Fathers Email required

example@example.com

Who does the scholar live with

Relationship to scholar

Only complete this section if there are any changes to your information.

Family Doctor

Phone number

Family Dentist

Phone number

Does the scholar have any illness or health problems that we should know about?

YesNo

If yes, please explain

Only complete this section if there are any changes to your information.

The following person(s) may check out my child.

(1st) Name

Address

Home

(2nd) Name

Address

Home Phone Number

Cell Phone Number

Other than yourself, give name(s) and telephone numbers(s) for emergencies:

Emergency Contact

Phone number

Has the scholar attended Lee County School District before?

YesNo

If so when

STATEMENT OF RESPONSIBILITY

You may find the 2024-2025 Parent/Student handbook on the district webpage at lcsdtrojans.net

Arkansas Code Annotated 6-18-502 requires school districts to provide parents and students with the following: the rules and regulations by which the school is governed the behaviors that will call for disciplinary actions the types of corrective actions that may be imposed Additionally, schools are required by state law to obtain documentation of student and parent receipt of student discipline policies. The statement must be signed and turned in to the homeroom teacher.

We have received the Lee County Parent-Student Handbook. We understand the District's discipline policies and realize that the student must adhere to these and to the other policies, rules, and procedures contained in the Handbook. In the event that we are not entirely certain of some aspect of school policy, we will contact the principal for clarification. I hereby release the District, its Board of Directors, staff, employees, and any institutions with which it is affiliated, from any and all claims and damages arising from my child's use of, or inability to use, the District's wide-area network. This includes but is not limited to claims that may arise from the unauthorized use of the system to purchase products or services. I understand that any user who violates this policy and accompanying regulations is subject to loss of network privilege as well as other District disciplinary actions. We acknowledge that we have read and understand Act 1149 of 1999 listed in the Appendix of this handbook regarding our parental responsibility for allowing a child to possess a weapon on school property. Act 574 of 1995 requires parents to inform school officials if their child has been expelled from school in any other school district or is a party to an expulsion proceeding. We hereby verify that the student we have enrolled in the Lee County School District has not been expelled from any other school district nor is a party to an expulsion proceeding at this time.

Please check the following acknowledgements below. By checking below and signing this sheet, you are signing for all forms indicated below.

I understand that this information is available to me online or I may ask the school district for a paper copy.I understand and will follow all of the testing rules and procedures listed on the State Assessment signature page.I understand and will follow the District's student internet/email usage agreement.I understand the photo/video release.

What is your photo/video release preference?*

YES, I DO give permission for my child to be photographed by LCSD or district-authorized media personnel.NO, I DO NOT give permission for my child to be photographed by LCSD or district-authorized media personnel.

Vision and Hearing Screening Permission*

I give permission for my child's personally identifiable information/student education records to be disclosed to a Third Party Billing Agent for the purpose of billing Medicaid and/or private insurance for Vision and Hearing Screening.

What is the best phone number to reach you on?*

What is your Child's School

What building will your child attend school?*

Whitten Pre-School (Pre-K)Anna Strong Learning Academy (K-6)Lee High School (7-12)

Student Signature*

ParentGuardian Signature*

RETURNING STUDENT GENERAL INFORMATION