Bradley County Schools Registration Form

Welcome to the Bradley County Schools Technology website. Registration Form for NEW students to Bradley County Schools. Please complete the form below. Required fields marked with an asterisk * If a question is not applicable, please leave the section blank or use N/A. You can change the language of the form at the bottom of the page.

School Year*

School Name*
Please select the school you wish to attend. Note for Preschool applicants: Please select Preschool as the School.

Grade*

Student Name (as it appears on the Birth Certificate):

First*

Middle*

Last*

Preferred Name

Gender:

Gender Male
Male

Gender Female
Female

Date of Birth*
MM slash DD slash YYYY

Country of Birth*

State of Birth*

County of Birth*

City of Birth*

Ethnicity - Please select Hispanic or Non-Hispanic*

Hispanic
Hispanic

Non-Hispanic
Non-Hispanic

Race (Check all that apply)*

Asian

American Indian/Alaskan Native

Black/African American

Pacific Islander/Native Hawaiian

White

Student Information:

Student's Address*

Student's City*

Student's State*

Student's Zip*

Student's Home Phone Number*

List other Children in Family

When a call is made about your child, what number should we call? Call #1*

Call #2*

Call #3

Call #4

Special Services he/she receives: [Pick all that apply]

Special Service Received:
RTI Reading

RTI Math

Speech

Does he/she have an IEP?
Yes

or 504 plan?
Yes

Emergency Contact Information [other than parent]:

Emergency Contact Name

Emergency Contact Phone

Emergency Relationship

Check Out Information: Names listed below may check out my child

Custody:*
Both Parents

Mother

Father

State Custody

Other Legal Guardian

Custody Issue?
No

Yes

What, if any, custody issues do we need to be aware of?

Mother's Information:

Mother's Name*

Maiden name*

Mother's Address (include City, State, Zip)*

Mother's Home Phone*

Mother's Cell Number

Employed By: Mother

Mother's Work Number

Mother's Email Address

Father's Information:

Father's Name*

Father's Address (include City, State, Zip)*

Father's Home Phone*

Father's Cell Number

Employed by: Father

Father's Work Number

Father's Email Address

Does the parent/legal guardian presently serve in the:
Active Military

National Guard Military

Reserve Military

Custody Other - Legal Guardian Information. If you do not need this section, please leave blank.

Custody/Legal Guardian's Name

Custody/Legal Guardian's Address (include City, State, Zip)

Custody/Legal Guardian's Number

Custody/Legal Guardian's Cell Number

Employed by: Custody/Legal Guardian

Custody/Legal Guardian's Work Number

Custody/Legal Guardian's Email Address

Custody/Legal Guardian's Relationship to Student

Last School Attended Information. If this is your child's first time in school, please leave blank.

School Last Attended by Student

School Last Attended Address

School Last Attended City

School Last Attended State

School Last Attended Zip

School Last Attended Phone Number

School Last Attended Fax Number

For children entering Kindergarten or First Grade check if attended - Pre-School
Yes

For children entering Kindergarten or First Grade check if attended - Day Care
Yes

For children entering Kindergarten or First Grade check if attended - Kindergarten
Yes

Do you plan to enter another school next year?
Yes

No

If Yes, where?

Parent or Legal Guardian's Signature*

Date*
MM slash DD slash YYYY

Student Name*

School*

Parent Guardian Name*

Student Phone Number*

STUDENT MEDICAL INFORMATION - My student has the following health conditions that may require special care during school hours:

MY CHILD HAS NO SPECIAL HEALTH NEEDS - If NO, please check box and skip to Primary Care Physician.
MY CHILD HAS NO SPECIAL HEALTH NEEDS

Please complete ONLY those that apply:

Asthma
Yes

Asthma Triggers

Asthma Treatment at home
Yes

an inhaler will be needed and provided for use during school
Yes

Diabetes
Yes

Diabetes - treated with Diet
Yes

Diabetes - treated with insulin injections or pump
Yes

Food Allergy
Yes

Food Allergy to:

Describe Reaction Food Allergy:

Current Required Treatment Food Allergy:

Other Allergy
Yes

Other Severe Allergy to:

Describe Reaction Other Allergy:

Current Required Treatment Other Allergy:

Vision Impairment
Yes

Glasses
Yes

Contacts
Yes

Hearing Impairment
Yes

Hearing Left
Yes

Hearing Right
Yes

Physical Impairment
Yes

Describe Physical Impairment:

Seizure Disorder
Yes

Seizure Type:

Seizure Treatment at home
Yes

Seizure Treatment: emergency medication is ordered and will be provided for use at school
Yes

Seizure Medication:

ADD/ADHD
Yes

ADD/ADHD: medicated at home
Yes

ADD/ADHD: will require medication during school hours (as prescribed by MD)
Yes

Other Medical Issues Not Listed Above:

Primary Care Physician

Doctor Office Phone Number

Consent:

The information provided above is true and accurate to the best of my knowledge.
Yes

I acknowledge that students cannot transport medication of any kinds. The parent must bring medication into school and sign appropriate paperwork.
Yes

It is my responsibility to notify the school if my child's medical condition changes and/or they have developed any medical needs that may require attention during school hours.
Yes

The school may use over-the-counter first aid products such as Neosporin, Benadryl spray/cream, wound cleanser, etc (Topical First Aide) as needed for my student as they have no known sensitivity to these items. This does not include medication taken by mouth.
Yes

Medicine by mouth?
Yes

No

The school may use over-the-counter Tylenol, Ibuprofen, cough drops, or TUMS as needed for my student as they have no known sensitivity to these items.
Yes

Medicine by mouth Tylenol, Ibuprofen, cough drops, or TUMS?
Yes

No

HOME LANGUAGE SURVEY - In an effort to comply with Title VI of the Civil Rights Acts, we have been asked to survey parents to see if we are meeting the needs of students who may speak English as their second language.

What is the first language that your child learned to speak?*

What language does your child speak most often outside of school?*

What language do people usually speak in your child’s home?*

Month Enrolled First School

Day Enrolled First School

Year Enrolled First School

Month entered US

Day entered US

Year entered US

STUDENT RESIDENCY INFORMATION - As part of the ESSA requirements, each school registrant should complete the following information. WHERE DOES THE STUDENT STAY AT NIGHT?

in His/Her home owned or rented by parent?
Yes

in a shelter?
Yes

with a relative or friend?
Yes

in a motel/hotel?
Yes

in housing that is inadequate?
Yes

unsheltered?
Yes

other?
Yes

If other, please explained:

Thank you for registering your student with Bradley County Schools. The principal or designee of the school you are applying to attend will contact you soon.

Requirements for all new students:

Immunization Record on a TN Certificate of Immunization

Updated Physical for Kindergarten – Physical must be completed during the current year.

Student Medical Form

Custody Paperwork – if needed

Proof of Address – must show parent name and service connection address

Proof of Birth, one of the following forms:

Birth Certificate – issued by a government

Passport issued by any nation (translated)

Immigration documentation

Decree of adoption issued by a court

Other official documentation showing date of birth and parent’s name (refer to board policy 6.203)

Requested if available: Child’s Social Security Card