NC WISE Registration Form



PowerSchool Registration Form (complete front and back)

|SCHOOL OFFICE USE ONLY |

| |Birth Certificate |

|NCWise Number: | |Address: |      |

|*Office Use Only* | | | |

|Legal Last Name: |      |City: |      |

|Legal First Name: |      |Zip: |      |

|Middle Name: |      | |

|Birth Date: |      |MAILING ADDRESS: |

|Country of Birth: |      |Address: |      |

|Social Security: |      |City: |      |

|Home Phone: |      |Zip: |      |

|Gender: | Male Female | | |

|Ethnicity: | Hispanic Non-Hispanic | | |

|Race: | Asian African-American American Indian Hawaiian/Pacific Islander White |

|PARENT/GUARDIAN INFORMATION |

|Child Lives With: | Mother Father Stepmother Stepfather Foster Parents Guardian Other: |

|Legal Custody: | Mother Father Stepmother Stepfather Foster Parents Guardian Other: |

|Mother: |      |Father: |      |

|Address/City/Zip: |      |Address/City/Zip: |      |

|Home Phone: |      |Home Phone: |      |

|Employer/Squadron: |      |Employer/Squadron: |      |

|Position/Rank: |      |Position/Rank: |      |

|Work Phone: |      |Work Phone: |      |

|Cell Phone: |      |Cell Phone: |      |

|Email Address: |      |Email Address: |      |

|Educational Level: |      |Educational Level: |      |

|Migrant Worker: | Yes No |Migrant Worker: | Yes No |

|EMERGENCY CONTACTS |

| |Contact 1 |Contact 2 |

|Full Name: |      |      |

|Relationship to Student: |      |      |

|Home Phone: |      |      |

|Work Phone: |      |      |

|Cell Phone: |      |      |

|MEDICAL |

|Doctor: |      |

|Medications: |      |

|SPECIAL NEEDS: |

| |IEP (Individualized Education Plan) | |PEP (Personalized Education Plan) |Other:       |

| |504 (Accommodation Plan) | |AIG (Academically/Intellectually Gifted) |Other:       |

|SIBLINGS: |

|Name: |      |School: |      |Grade: |      |

|Name: |      |School: |      |Grade: |      |

|Name: |      |School: |      |Grade: |      |

|Name: |      |School: |      |Grade: |      |

|MILITARY INFORMATION |

|Name |Rank |Relationship to Student |Branch of Service |Squadron/Unit |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|OTHER |

|Has this student ever attended a Wayne County public school? | Yes No |

|If yes, please give the name of the schools: |      |

| | |

|I am aware that I must provide within 30 calendar days the item indicated to avoid suspension. | Yes No |

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|Signature | |Date |

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|Comments: | | |

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