Middle and High School Registration Form

Bentworth School District

Student Registration Form

Date:*

Answer Required

Grade:*

Answer Required

Fifth (5)

Sixth (6)

Seventh (7)

Eighth (8)

Ninth (9)

Tenth (10)

Eleventh (11)

Twelfth (12)

Student's Legal First Name*

Answer Required

Student's Legal Middle Name

Answer Required

Student's Legal Last Name*

Answer Required

Preferred Name

Answer Required

Current Address

Street Address*

Answer Required

City*

Answer Required

Zip/Postal*

Answer Required

Date of Birth*

Answer Required

Birthplace:*

Answer Required

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

Answer Required

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

Yes

Option

Race:*

Answer Required

White

Black

Asian

American Indian/Alaskan Native

Pacific Islander

Parent Information

Father's First Name:*

Answer Required

Father's Middle Name

Answer Required

Father's Last Name*

Answer Required

Email*

Answer Required

Mobile Phone*

Number Required

Work Phone

Number Required

Address

Street Address*

Answer Required

City*

Answer Required

Zip/Postal*

Answer Required

Occupation:*

Answer Required

Does this address require a separate mailing?*

Answer Required

Yes

Mother's First Name (and Maiden)*

Answer Required

Mother's Middle Name

Answer Required

Mother's Last Name*

Answer Required

Email*

Answer Required

Mobile Phone*

Number Required

Work Phone

Number Required

Address

Street Address*

Answer Required

City*

Answer Required

Zip/Postal*

Answer Required

Occupation:*

Answer Required

Does this address require a separate mailing?*

Answer Required

Yes

Siblings

Number of brothers?*

Answer Required

Number of sisters?*

Answer Required

Bus number and bus stop:

Answer Required

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

Guardian's Middle Name

Answer Required

Guardian's Last Name*

Answer Required

Relationship to Student*

Answer Required

Foster Child:

Answer Required

Yes

Agency:

Answer Required

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

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

Yes

Do you have the immunization record?*

Answer Required

Yes

SIGNATURES

Parent / Legal Guardian Signature*

Answer Required

Please fix the highlighted areas below before submitting.

Middle and High School Registration Form