Robstown Independent School District

21^st Century Project C.L.U.E.

School:______________________

Registration Form / forma de inscripción

 Student’s Full Name/ Nombre: ____________________________ SS#/Seguro Social:____________________

Date of birth / Fecha de nacimiento: ___/___/_____ Teacher/Maestra(o):_____________Grade/Grado:_______

Address/Dirección: ____________________________________________Bus:          No      Yes Bus #_________

Does the child live with / el niño vive con:       mother/madre          father/padre         guardian/guardian

Mother’s Name/Nombre de madre:___________________________________________________

Phone Number/Teléfono de: Home/Casa:____________Work/Trabajo: ____________ Cell/Celular__________

Father’s Name/Nombre de padre:____________________________________________________

Phone Number/Teléfono de: Home/Casa:____________Work/Trabajo: ____________ Cell/Celular__________

Brothers and sisters attending school

                     Name                                             Age                                       School Attending

___________________________             ____________          _______________________________________

___________________________             ____________          _______________________________________

___________________________             ____________          _______________________________________

___________________________             ____________          _______________________________________

Alternate people who have permission to pick up your child/Algunas otras personas que tienen permiso para recoger a su niño:

Name/Nombre:____________________________ Relation to child/relación al niño:______________________

Name/Nombre:____________________________ Relation to child/relación al niño:______________________

In case of an emergency/contacto en caso de emergencia:

Name/Nombre: ____________________________ Emergency phone #/numero de emergencia:_____________

Please list any pertinent medical information (allergies, physical handicaps) of which we should be aware of/Liste por favor información médica pertinente (alergias, las desventajas físicas) de que debemos estar enterados de: ______________________________________________________________________________

Disruptive, disrespectful or other prohibited behavior is reason for disciplinary action, such as expulsion from the program. Perturbar, irrespetuoso, y otra conducta prohibida es razón de castigo y expulsión del programa.

Yes, I hereby grant permission to use my child’s name, picture, art, written work, voice, or picture (video or still) to appear in any school publicity or publication, school buildings, school videos, or website.

No, I do not want my child’s name, picture, art work, voice, or picture (video or still) to appear in any school publicity or publication, school buildings, school videos, or website.

___________________________________________                                  ________________________

Parent’s Siganture / Firma del padre                                                                              Date / Fecha