Rev. 6/02/2020
Date(s) Last Attended:
PRIOR SCHOOL INFORMATION
School Last Attended:
Address:
Contact:
Phone:
Is your child currently attending, or has your child ever attended a Maryland Public School or a Frederick County Public School? Yes No
If YES, please provide school district name:
Is the student currently expelled or suspended from another school? Yes No If yes, school will refer to PPW
Is the student transferring from an alternative school? Yes No If yes, school will refer to PPW
SPECIAL SER
VICES
Was your child enrolled in a special program? Yes No
If yes, please specify: Special Education: Hours of service: 504 Plan Student Support Teacher Services
Court Placement: Residential Other
English Language Learner Specify one: Beginner Intermediate Advanced
EMERGENCY CONTACTS (OTHER THAN LEGAL PARENT/GUARDIAN)
DAY CARE PROVIDER: Name, House Number/Street Name, City / State / Zip Code
Phone Numbers: Cell: Home:
OTHER HOUSEHOLD MEMBERS:
HEALTH C
ONCERNS (e.g., takes daily medications, wears glasses, hearing problem, allergies, diabetic, etc.)
Describe:
Immunization records on file? Yes No
Has the child received a physical examination in the past 9 months? Yes No
Is DHMH on file? Yes No If no, give reason: Insufficient financial resources Lack of access to care
Community Services (optional): If your family has been in contact and/or has received services from outside agencies, please indicate (e.g.,
Mental Health, Social Services, Community Agency School Services (CASS):
DISCLAI
MER: Your son/daughter has been enrolled on the basis of available information.
Upon receipt of all records and information, formal enrollment will be completed. Any person who willfully makes a material misrepresentation shall
be subject to a penalty payable to the County for three times the pro rata share of tuition for the time the child fraudulently attends a Frederick
County Public School.
*Contact information provided in this document will be used by authorized FCPS and Frederick County Health Department (FCHD) employees to
contact parent(s)/guardian(s) of students when necessary
.
Signature: ____________________
_______________________________________________________ Date: ____________________________
Name: Relationship to Student:
Address (if different from student) House Number / Street Name / Apartment Number
/ PO Box / City / State / Zip Code
Home:
Work:
Phone Numbers: Cell:
Name: Relationship to Student:
Email:
Address (if different from student) House Number / Street Name / Apartment
Number / PO Box / City / State / Zip Code
Home:
Work:
Phone Numbers: Cell:
Email:
Name, Date of Birth, Relationship to student
Name, Date of Birth, Relationship to student
Name, Date of Birth, Relationship to student
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