District # 2149 409 4th St. S.E. School:
Minnewaska Area Elementary
Medical information:
Student’s Legal Last Name
Student’s Legal First Name:
Non-aspirin (acetaminophen or Tylenol) will be provided when necessary ONLY in the case of low-grade fever.
I DO give permission for the school nurse/staff to give my student an initial dose of non-aspirin (Tylenol) in the appropriate
Middle Name
Nick Name
dosage if needed for low-grade fever in accordance with a standing order of the school’s consulting physician. I DO NOT give permission for my student to have non-aspirin.
Birthdate BC Grade:
Parent signature________________________________________________________Date______________________
Male Female
Registration is for:
2. Ethnicity
5. If your child has an active IEP? Please
identify student’s primary disability:
If any medication (prescription or over-the-counter) is to be given by school staff on a regular schedule, please contact the School Is this student a new or returning
Developmental Cognitive Disabilities (mild) Please consult the student handbook for the complete medication policy adopted by the Board of Education. student to 2149
Developmental Cognitive Disabilities (Severe) **Is your student taking any medication on a regular basis at ______home_____school? 3. Student has been identified as
or is receiving services for:
Name of medication/dosage__________________________________________________________________ Does Students have any Allergies?
Has/Is student being treated for any of the following Physical
Health concerns?
Reaction kit at school? Other/Comments: 4. Will student use busing?
School most recently attended by student (Name, District #, city,
Dates of Attendance
Primary/Secondary Language Information

Which Language did your child learn first? English Other (specify):_____________________________
Which Language is most often spoken in your home? English Other (specify):_____________________________ Which Language does your child usually speak? FAMILY INFORMATION *
English Other (specify):_____________________________ Parent/Guardian #1 is the primary contact for district announcements and mailings. Street Address
Mailing address (if different than street address)
City, State, Zip
Home Phone
Student Lives with:
Student is resident
School Reach
Mother Father Both of District 2149
Check all boxes you want to receive School Reach instant Resident Parent/Guardian #1
First Name
Cell # School Reach
Relationship to Student (mother, father, grandparent etc.) Status of Parents:
Last Name
School Reach
Resident Parent/Guardian #1
First Name
Cell# School Reach
Relationship to Student (mother, father, grandparent etc.) Mailing address if different than
Last Name
street address:
School Reach

Add 2nd Household Mailing-Parent/Guardian #2
Mailing Parent/Guardian #2 Name:
City, State, Zip
School Reach
Add A Different Mailing Address
Mailing Parent/Guardian #2 Mailing Address:
The Family Education Records and Privacy Act provides that educational records are made available to each parent of a student. Name of persons to call in an emergency other than a person the student lives with and who can pick up the student if necessary: I CERTIFY THAT THE INFORMATION I PROVIDED IS TRUE AND CORRECT:
Other Household Members under


school age
Census: Name Birthdate Census: Name Birthdate Emergency #3 Name

Source: http://www.minnewaska.k12.mn.us/schools/minnewaska%20area%20elementary/postings/New%20student%20registration-information%20form.pdf


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