WICKLIFFE ELEMENTARY SCHOOL				Grades PRE-K - 8		Phone 918-434-5559  Fax 918-434-5515
11176 E 470						Office Use Only
Salina Oklahoma 74436		(Please print all information except signature)				ID#______________________________
Student Enrollment Information						DOB_____________________________
Has student ever attended Wickliffe School?			□Yes	□No		GRADE_______
						SS#____________________________
Students Legal Name   _______________________________________________________________________________________
(as shown on the birth certificate)		(Legal Last)	(First)	(Middle)	(Goes by Nickname)	(Last Name if different from Legal Name)
Students Home Address  _____________________________________________________________________________________
						(City)		(Zip)
Parent/Guardian Home Phone       918-________________________					Who has Legal Custody?  ___________________________
Student Date of Birth         ___________________________________					Student Social Security #   ___________________________
	(month)	(day)	(year)
Ethnic Origin  (check one)	□		□	□	□			□
	Asian or Pacific Islander		Black	Hispanic	Alaskan or American Indian			White or Other
Do you live on "Restricted Indian Land?			□Yes	□No
Name of Other Schools Attended				Name(s),  Age(s) and Grade(s) of Other Children living in the home
Student Lives with? (check all that apply)		□ □	□		□	□		□      □
		(mother)  (father)	(mother/stepfather)		(father/stepmother)	(grandmother)		(grandfather)      (other)
Parent/Guardian 1    _____________________________________________________					Relationship    ____________________________________
(Mother)	(Last)	(First)	(Middle)
Employer  ______________________________________				Work phone  918-______________				Cell 918-_____________
Parent/Guardian 2    _____________________________________________________					Relationship    ____________________________________
(Father)	(Last)	(First)	(Middle)
Employer  ______________________________________				Work phone  918-______________				Cell 918-_____________
Emergency Contact  1  ______________________________________________________________________________________
	(other than guardian shown above)
Emergency Contact  2  ______________________________________________________________________________________
	(other than guardian shown above)
Name of Physician:			Phone #  918-
In case of serious accident or illness when guardian cannot be contacted,
do we have permission to take your child to a doctor or hospital?				□Yes □No
Is student currently under suspension at previous school?    YES    NO			□Yes □No
Has student been in any kind of special needs class?    YES    NO  If yes specify:___________________________________________			□Yes □No
Does student receive Medicaid benefits?  YES    NO     If yes Medicaid #  _______________________________________
Students Photo may be used in publications?			□Yes □No
Students information may be used in school directory?			□Yes □No
I also affirm that the facts stated herein are true.			Any false statement subjects the above named student to immediate withdraw .
Parent or Guardian Signature  _____________________________________________						Date _______________________
	If at any time this information changes, Please notify the school.
								Revised 4/11/2006