Middle and High School Registration Form

Bentworth School District

Student Registration Form

Date:*

Answer required for "Date:"

Grade:*

Answer required for "Grade:"

Fifth (5)

Sixth (6)

Seventh (7)

Eighth (8)

Ninth (9)

Tenth (10)

Eleventh (11)

Twelfth (12)

Student's Legal First Name*

Answer required for "Student's Legal First Name"

Student's Legal Middle Name

Answer required for "Student's Legal Middle Name"

Student's Legal Last Name*

Answer required for "Student's Legal Last Name"

Preferred Name

Answer required for "Preferred Name"

Current Address

Street Address*

Answer required for "Street Address"

City*

Answer required for "City"

Zip/Postal*

Answer required for "Zip/Postal"

Date of Birth*

Answer required for "Date of Birth"

Birthplace:*

Answer required for "Birthplace:"

Date of Entry to the State of Pennsylvania (If not born in PA):*

Answer required for "Date of Entry to the State of Pennsylvania (If not born in PA):"

Are you Hispanic or Latino? (A person of Cuban, Mexican, Puerto Rican, South or Central America, or other Spanish culture or origin, regardless of race.) Please respond in the following question.

The following question is about ethnicity and not race.

Are you Hispanic or Latino?*

Answer required for "Are you Hispanic or Latino?"

Yes

Option

Race:*

Answer required for "Race:"

White

Black

Asian

American Indian/Alaskan Native

Pacific Islander

Parent Information

Father's First Name:*

Answer required for "Father's First Name:"

Father's Middle Name

Answer required for "Father's Middle Name"

Father's Last Name*

Answer required for "Father's Last Name"

Email*

Answer required for "Email"

Mobile Phone*

Number Required

Work Phone

Number Required

Address

Street Address*

Answer required for "Street Address"

City*

Answer required for "City"

Zip/Postal*

Answer required for "Zip/Postal"

Occupation:*

Answer required for "Occupation:"

Does this address require a separate mailing?*

Answer required for "Does this address require a separate mailing?"

Yes

Mother's First Name (and Maiden)*

Answer required for "Mother's First Name (and Maiden)"

Mother's Middle Name

Answer required for "Mother's Middle Name"

Mother's Last Name*

Answer required for "Mother's Last Name"

Email*

Answer required for "Email"

Mobile Phone*

Number Required

Work Phone

Number Required

Address

Street Address*

Answer required for "Street Address"

City*

Answer required for "City"

Zip/Postal*

Answer required for "Zip/Postal"

Occupation:*

Answer required for "Occupation:"

Does this address require a separate mailing?*

Answer required for "Does this address require a separate mailing?"

Yes

Siblings

Number of brothers?*

Answer required for "Number of brothers?"

Number of sisters?*

Answer required for "Number of sisters?"

Bus number and bus stop:

Answer required for "Bus number and bus stop:"

Guardian Information

If a child lives with someone other than parent please complete the following. If not, please put N/A in each space.

Guardian's First Name:*

Answer required for "Guardian's First Name:"

Guardian's Middle Name

Answer required for "Guardian's Middle Name"

Guardian's Last Name*

Answer required for "Guardian's Last Name"

Relationship to Student*

Answer required for "Relationship to Student"

Foster Child:

Answer required for "Foster Child:"

Yes

Agency:

Answer required for "Agency:"

Please attach a copy of the signed order by the Judge of Orphans Court. If a student lives with someone other than natural mother or father and does not have a court appointed guardian then a 1302 affidavit must be completed.

Documentation of Residency in the Bentworth School District (Must have at least two)*

Answer required for "Documentation of Residency in the Bentworth School District (Must have at least two)"

Wage Statement

Social security Check

Current Year Wage Tax Receipt

Public Assistance

Utility Bills

Rental Agreement

Other:

Do you have the Birth Certificate?*

Answer required for "Do you have the Birth Certificate?"

Yes

Do you have the immunization record?*

Answer required for "Do you have the immunization record?"

Yes

SIGNATURES

Parent / Legal Guardian Signature*

Answer required for "Parent / Legal Guardian Signature"

Please fix the highlighted areas below before submitting.

Middle and High School Registration Form