1. 1
FAYETTE COUNTY PUBLIC SCHOOLS REGISTRATION APPLICATION FORM
For School Use Only
Enrollment Date:
Enrollment Code:
Student Number:
TIME/DATE STAMP
Room:
Teacher:
Grid #
Geo Code:
Neighborhood #
Transportation Code:
Bus Stop:
Last Name
AM Bus:
Date Cum Requested:
STUDENT INFORMATION
First Name
Middle
Physical Address
Student’s Birth Date
Score:
State
Sex
F
Last School or Preschool Attended
Grade
City
Student’s Social Security # (Optional)
Asian
Native Hawaiian or Other Pacific Islander
Zip
Is the student Hispanic/Latino?
Yes
No
M
American Indian or Alaska Native
Race – Required (Check one or more):
PM Bus:
Nickname
Apt
Phone
HR:
White
Grade Completed
Black or African American
Address
Telephone
Other Information (Please check if applicable):
IEP
504 Plan
Primary Language:
Foster Home
English
PE Waiver
Migrant
Homeless
Refugee/Immigrant
Other: _________________________________________________
HOUSEHOLD AND PARENT/GUARDIAN INFORMATION
PARENT/GUARDIAN #1
Last Name
First Name
Middle Name
Sex
F
Relationship to Student:
Home Phone
Parent
Guardian
Stepparent
Work Phone
Other ______________________
Cell Phone
Address (if different from student’s)
Employer
PARENT/GUARDIAN #2
Last Name
Relationship to Student:
Home Phone
Occupation
First Name
,
DOB:
Apt
Other Phone
State
Work Address
Sex
Middle Name
F
Foster Parent
Stepparent
Work Phone
Other ______________________
Cell Phone
Apt
Work Address
Zip
Work Hours
Guardian
Occupation
Guardian 1 Email Address
City
Parent
Address (if different from student’s)
Employer
Foster Parent
M
Lives with student?
Yes
No
City
M
Lives with student?
Yes
No
Guardian 2 Email Address
Other Phone
State
Zip
Work Hours
Please complete other side

2. 2
SIBLINGS (please attach additional sheet if more room is needed)
Name
Birthdate Grade School
Sex
F
M
F
M
F
M
F
Address (if different from student’s)
M
EMERGENCY INFORMATION OTHER THAN PARENT/GUARDIAN
Last Name
First Name
Sex
Middle Name
F
Mailing Address
Home Phone
City
Work Phone
State
Zip
Permission to pick up child from
school?
Yes
No
Relationship to Student
Cell Phone
M
Persons who may not pick up your child: (If this is a parent, school must be supplied with court documentation)
Name
Relationship
Court document supplied?
Yes
No
Does your child have any severe or chronic medical conditions? If yes, please explain.
Physician’s Name
Phone Number
Emergency Room Preference (If any)
KINDERGARTEN KICKOFF INFORMATION
Every school in Fayette County will host a Kickoff event for incoming kindergarten students prior to the start of school
either in late July or August. Students will be given an appointment to come meet school staff and teachers and
participate in a learning screener. Schools may sign families up during kindergarten registration for Kindergarten
Kickoff or families will be contacted by the child’s assigned school at a later time with Kickoff information.
ANY ADDITIONAL PARENT COMMENTS:
FOR OFFICE USE ONLY
ENROLLMENT PRIORITIES
Address in primary attendance area?
Student subject to prior board action?
Older siblings at this school?
Employee teaching at this school or campus?
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
No
No
Number:
Date:
Date:
Date:
Date:
No
No
No
No
DOCUMENTATION PROVIDED
Address Documentation #1
Address Documentation #2
Birth Certificate
Immunization Record
Preventative Health Care Examination
Eye Exam (Kindergarten Only)
Dental Exam (Kindergarten Only)
Social Security Card (not required)
Court Documents (if applicable)
Kindergarten Verification (if applicable)
Records Release Request (if applicable)
,
DOB:
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
Yes
Yes
Yes

3. 3
FAYETTE CO PUBLIC SCHOOLS HOUSEHOLD FORM
STUDENT INFORMATION (PLEASE PRINT)
Student Last Name
Student First Name
Student Middle Name
Green
14-15
Date of Birth
School
Revised 12/07/13
Sex
Female Male
Grade Level
Home Phone Number _____________________________________
Address
Apt
City
PARENT/GUARDIAN #1
Guardian Last Name
Guardian First Name
State
Geo Code (School Only)
Zip Code
Guardian Middle Name
Is Guardian former
FCPS student?
Sex
Yes Female Male
Relationship to Student:
 Parent
 Stepparent
Cell Phone
 Guardian
 Foster Parent
 Other: _________________
Other Phone
Work Phone
Mailing Address (If student not living with guardian)
Yes
Guardian lives with student?
Guardian Email Address
Apt
PARENT/GUARDIAN #2
Guardian Last Name
Guardian First Name
City
State
Guardian Middle Name
Zip Code
Is Guardian former
Sex
Yes Female
Guardian lives with student?
 Yes
Should this Guardian receive mailing?
 Yes
Have rights to online student info?
 Yes
FCPS student?
Relationship to Student:
 Parent
 Stepparent
Cell Phone
 Guardian
 Foster Parent
 Other: _________________
Other Phone
Work Phone
Mailing Address (If student not living with guardian)
Apt
City
State
Sex
Female
Cell Phone
Secondary Contact Last Name
Home Phone
Third Contact Last Name
Home Phone
First Name
Cell Phone
First Name
Cell Phone
Male
No
No
No
Guardian Email Address
EMERGENCY CONTACTS - OTHER THAN GUARDIAN
Primary Contact Last Name
First Name
Middle Name
Home Phone
No
Work Phone
Middle Name
Work Phone
Middle Name
Work Phone
Zip Code
Relationship to Student
Male
Home Address
Sex
Female
Relationship to Student
Male
Home Address
Sex
 Female
Relationship to Student
Male
Home Address
*IF YOU HAVE ADDITIONAL STUDENTS ATTENDING FAYETTE CO. SCHOOLS WITH SAME
GUARDIANS, ADDRESS AND EMERGENCY CONTACTS PLEASE COMPLETE OTHER SIDE.
I certify the above information is correct and
understand that I must contact the school with
any changes.
,
DOB:
__________________________________________________________________
Signature
Date

4. 4
O n l y co mp l ete i f you h ave ad d i ti on al ch i l d ren atten d i n g Fayette Cou n ty S ch o o l s w i th
th e S AME GUA RD I ANS , ADDRE S S AND E ME RGE NC Y CO NT ACT S .
Ad d i ti on al S tu d ent I n f ormati on
STUDENT LEGAL NAME (Last Name, First Name Middle Name)
(please print)
DATE OF BIRTH
SCHOOL
SEX
Female Male
GRADE
Ad d i ti on al S tu d en t I n f ormati on
STUDENT LEGAL NAME (Last Name, First Name Middle Name)
(please print)
DATE OF BIRTH
SCHOOL
SEX
Female Male
GRADE
Ad d i ti on al S tu d en t I n f ormati on
STUDENT LEGAL NAME (Last Name, First Name Middle Name)
(please print)
DATE OF BIRTH
SCHOOL
SEX
Female Male
GRADE
Ad d i ti on al S tu d en t I n f ormati on
STUDENT LEGAL NAME (Last Name, First Name Middle Name)
(please print)
DATE OF BIRTH
SCHOOL
SEX
Female Male
GRADE
Ad d i ti on al S tu d ent I n f ormati on
STUDENT LEGAL NAME (Last Name, First Name Middle Name)
(please print)
DATE OF BIRTH
SCHOOL
SEX
Female Male
GRADE
Ad d i ti on al S tu d en t I n f ormati on
STUDENT LEGAL NAME (Last Name, First Name Middle Name)
(please print)
DATE OF BIRTH
SCHOOL
SEX
Female Male
GRADE
Ad d i ti on al S tu d en t I n f ormati on
STUDENT LEGAL NAME (Last Name, First Name Middle Name)
(please print)
DATE OF BIRTH
SCHOOL
SEX
Female Male
GRADE
Guardian information on the other side MUST be completed.
I certify the above information is correct and
understand that I must contact the school with
any changes.
GREEN
,
DOB:
__________________________________________________________________
Signature
Date
Revised 12/07/13

5. “It’s About Kids”
FAYETTE COUNTY PUBLIC SCHOOLS
1126 Russell Cave Road
Lexington, KY 40505
(859) 381-4100
Student Health Information
(Please complete one form per student)
2014-15
SCHOOL YEAR: ________________
SCHOOL: _______________________________________________________________
STUDENT INFORMATION (Please give student’s complete legal name)
Last Name
First Name
Student’s Social Security #
Middle Name
Student’s Birth Date
Race-Required (check one or more):
Street Address
Homeroom Teacher
Sex
F
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Apt
City
Is the student Hispanic/Latino?
Yes
No
M
Asian
White
Black or African American
Zip
PARENT/GUARDIAN AND EMERGENCY CONTACT INFORMATION
Guardian 1 Name
Relationship to Student
Home Phone
Work Phone
Cell Phone
Guardian 2 Name
Relationship to Student
Home Phone
Work Phone
Cell Phone
Emergency Contact (Other than Guardian)
Relationship to Student
Home Phone
Work Phone
Cell Phone
STUDENT’S Medical Insurance
Does your student have a KY Medicaid or K-CHIP Card?
Does your student have other medical insurance?
Yes
Yes
No
No
Number ______________________________________
Name of Company__________________________________
STUDENT’S Medical History
1) Significant Medical History: ________________________________________________________________________
2) Medication Allergies: _____________________________ Food Allergies: __________________________________
3) Other Allergies: __________________________________________________________________________________
4) Medications taken Daily: __________________________________________________________________________
5) * Prescription Medication to be given at School: _______________________________________________________
Student’s Health Care Provider: __________________________________________ Phone: __________________________
*Must complete Medication Consent Forms prior to any prescription medications being brought to school to be administered. Forms are available at
school.
Does your student have any of the following life-threatening conditions that may require
EMERGENCY treatment or medications to be given at school?
DIABETES
(Glucagon)
ASTHMA
(Rescue Inhaler)
SEIZURES
(Diastat)
LIFE-THREATENING
ALLERGY (Epi-Pen)
OTHER:
_____________________
CONSENT FOR HEALTH SERVICES
All students will receive basic First Aid and emergency care. By signing this form, I consent to Health Services given to my
student while at school. I authorize Fayette County Public Schools to release medical information about my student to
his/her Primary Care Provider.
EXPIRES ONE YEAR AFTER DATE SIGNED.
X_______________________________
(Signature of Parent / Legal Guardian / Emancipated Student)
___ /___ /________
(Date signed)
THIS SECTION FOR SCHOOL USE ONLY
Care Plan(s)
Sent
Rev. 12/2013
Date: _____________
Date: _____________
Date: _______________
Date: ________________
Care Plan(s) Returned
Date: _________________
Please Return Completed Form To School
Date: __________________
5

6. 6
Fayette County Public Schools
HOME LANGUAGE SURVEY
Date 1/30/14
School ________________________________________ Grade
________________________
Child's Name ________________________________________________________________________________________________
First Name
Middle Initial
Last Name
Parent or Guardian's Name _____________________________________________________________________________________
First Name
Middle Initial
Last Name
Address ____________________________________________________________________________________________________
Street
City
State
Zip
Phone Number _______________________________________________________________________________________________
Home
1.
Work
_______________________ (Month/Date/Year)
Was your child born in the United States?
If yes, in which state?
❏ Yes
❏ No
_____________________________________
If no, in what other country?
_____________________________________
If no, date child entered the United States:
2.
Child’s date of birth:
_______________________ (Month/Date/Year)
Has your child attended any school in the United States
for any three years during their lifetime?
Yes
If yes, please provide school name(s), state, and dates attended:
Name of School _______________________________________________
Name of School _______________________________________________
Name of School _______________________________________________
State ________
State ________
State ________
No
Dates Attended _________________
Dates Attended _________________
Dates Attended _________________
3.
What is the language most frequently spoken at home?
_____________________________________
4.
If available, in what language would you prefer to receive
communication from the school?
_____________________________________
5.
6.
Please check if your child is:
A. ❏ Native American Indian
B. ❏ Alaska Native
C.
D.
❏
❏
Native Pacific Islander
Native U.S. Virgin Islander
❏
Is your child’s first-learned or home language anything other than English?
Yes
❏
No
If you responded “Yes” to question number 6 above, please answer the following questions:
7.
In what country did your child most recently reside?
_____________________________________
8.
Which language did your child learn when he/she first began to talk?
_____________________________________
9.
What language does your child most frequently speak at home?
_____________________________________
10.
What language do you most frequently speak to your child?
(Father) _____________________________________
(Mother) _____________________________________
11.
Please describe the language understood by your child. (Check only one)
A. ❏
Understands only the home language and no English.
B. ❏
Understands mostly the home language and some English.
C. ❏
Understands the home language and English equally.
D. ❏
Understands mostly English and some of the home language.
E. ❏
Understands only English.
________________________________________________
Parent or Guardian's Signature
_____________________________________
Date
OFFICE USE ONLY
Student ID #
Date Distributed
00NCLB-B1 (Rev. 03/05 US)
Date Received
© 2005 TransACT Communications, Inc.
P02028