PRIMARY GUARDIAN 1 EMPLOYER (Company Name) Employer Phone
PRIMARY GUARDIAN 2 EMPLOYER (Company Name) Employer Phone
Last Name First Name
(non-custodial parent/guardian not residing with student)
RELATIONSHIP TO STUDENT
Last Name First Name
SECOND HOUSEHOLD (non-custodial parent not residing with student)
SECOND HOUSEHOLD ADDRESS (Street/Apt #, City, State, ZIP)
Additional Mailings Requested?
IS THERE A CUSTODY OR PARENTING PLAN IN EFFECT? Yes No
If yes, please provide a copy for your child’s school file.
IS THERE A RESTRAINING ORDER IN EFFECT? Yes No
If yes, legal papers must be on file with the school for enforcement. Copy Received? Yes No
Restraining order is against: Mother Father Other
SCHOOL PREVIOUSLY ATTENDED: SCHOOL DISTRICT PREVIOUSLY ATTENDED:
PREVIOUS SCHOOL LOCATION: (Address, City, State)
Has Student Ever Attended Olympia School District Schools? Yes No If yes, School:
Has Your Child Ever Been Enrolled In A Preschool Program? Yes No
Has Student Ever Attended A Washington State School? Yes No Date(s) Attended (Month/Year)
DOES YOUR CHILD HAVE A LIFE THREATENING CONDITION? No Yes
If yes, additional information is required prior to your child attending school. Please complete and return the supplemental Life
Threatening Conditions packet. According to RCW 28A.210.320: Children with life-threatening health conditions – Medication or
treatment orders – Rules, the medication or treatment order must address the life-threatening condition and it must be on file with the
school prior to the child attending school. Under the law, “life-threatening condition” means a health condition that will put the child in
danger of death during the school day if a medication or treatment order is not in place. The law provides that a child may not attend
school in the absence of a medication or treatment order if the child has a life-threatening condition that might require medical services
to be provided at school.
Packet given to parent/legal guardian
Date packet given: Authorized office staff signed Parent/Legal Guardian signed
THIS SECTION IS FOR OFFICE USE ONLY
Has your child ever qualified for, or been enrolled in, a special education program? No Yes If yes, at what grade level(s)?
Has your child ever qualified for, or had, a 504 plan? No Yes If yes, at what grade level(s)?
Has your child ever participated in:
LAP Gifted Other? No Yes If yes, at what grade level(s)?
Has your child ever been enrolled in an, English Learner (EL) Program? No Yes If yes, at what grade level(s)?
Primary language spoken at home:
Has your child ever been retained?
No Yes If yes, at what grade level(s)?
Has your child ever been promoted? No Yes If yes, at what grade level(s)?
Has your child ever had a BECCA petition filed on them? No Yes If yes, at what grade level(s)?
Has your child ever been suspended or expelled? No Yes If yes, at what grade level(s)?
Is your child currently living in: a shelter, car, motel, doubled-up with friends/relatives,
in temporary foster care or group home, or campground? No Yes If yes, at what grade level(s)?
DOES STUDENT ATTEND CHILDCARE? Before school After school Before and after school
Childcare Provider’s Name Address Phone Number