Thank you for taking the time to complete this Student Data Form. This information is necessary for us to provide all of our students with a safe and productive learning environment. All students registered at JRTI must have this information on file.

Instructions

Make sure you are using a modern browser such as Chrome, FireFox, Safari, or Edge. Older browsers are not supported.
Please fill out this online form as completely as possible. All fields marked with a red asterisk (*) are required.
After you submit this form, check your email for a response.
Download the two-page signature form regarding school policies. This form is required to complete registration.
1. Refer to the Resources section of this website for policy information.
2. Print the signature form, and return it to JRTI with all of the required signatures.
3. The signature form can be submitted in person or mailed to:

James Rumsey Technical Institute
3274 Hedgesville Rd
Martinsburg, WV 25403

Student Information

ID Number

This is the student's WVEIS number (lunch number). If you are an adult or homeschooled, you may not have an ID number yet. If this is the case, please enter "none yet."

First Name

Middle Name

Last Name

Name Suffix

Nickname

Social Security Number

Birth Date

Birthplace

Gender

Female Male

Ethnicity

Street Address 1

Street Address 2

City

State

Zip Code

Temporary Living Arrangements

Yes No Is this address temporary living arrangements?

Living Arrangements Due to Economic Hardship

Yes No Is this due to economic hardship?

School Information

Home High School

Which school is the student enrolled in?

Other School

If other, please tell us the name of the school.

Homeschooled

No Yes Is the student homeschooled?

Grade

11 12 Adult Which grade will the student be in for the upcoming school year?

Bus Number

Alternate Bus Pickup/Drop-off

Understands Emergency Dismissal Plan

Yes No Does the student understand the plan to be followed in case school is dismissed prior to regular time for emergency or inclement weather?

Permissions

Permission for Field Trips

Yes No Does the student have permission to go on school-related walking field trips?

Permission to Participate in Fundraisers

Yes No Does the student have permission to participate in school fundraisers?

Permission to Use Photos and Video

Yes No James Rumsey Technical Institute has my permission to use photos & video recordings of my student for media and online publications.

Guardians

Please provide information for up to four guardians including parents, adults living in the same home as the student, and anyone who will serve as emergency contacts.

Guardian 1

Guardian 1 Relationship

Father Mother Legal Guardian Other

Guardian 1 Full Name

Guardian 1 Street Address 1

Address Line 1

Guardian 1 Street Address 2

Address Line 2

Guardian 1 City

City

Guardian 1 State

State

Guardian 1 Postal Code

Zip

Guardian 1 Email Address

Guardian 1 Cell Phone

Guardian 1 Home Phone

Guardian 1 Home Phone Unlisted

Yes No

Guardian 1 Employer

Guardian 1 Occupation

Guardian 1 Work Phone

Guardian 1 Work Phone Extension

Guardian 2

Guardian 2 Relationship

Father Mother Legal Guardian Other

Guardian 2 Full Name

Guardian 2 Street Address 1

Address Line 1

Guardian 2 Street Address 2

Address Line 2

Guardian 2 City

City

Guardian 2 State

State

Guardian 2 Postal Code

Zip

Guardian 2 Email Address

Guardian 2 Cell Phone

Guardian 2 Home Phone

Guardian 2 Home Phone Unlisted

Yes No

Guardian 2 Occupation

Guardian 2 Employer

Guardian 2 Work Phone

Guardian 2 Work Phone Extension

Guardian 3

Guardian 3 Relationship

Father Mother Legal Guardian Other

Guardian 3 Full Name

Guardian 3 Street Address 1

Address Line 1

Guardian 3 Street Address 2

Address Line 2

Guardian 3 City

City

Guardian 3 State

State

Guardian 3 Postal Code

Zip

Guardian 3 Email Address

Guardian 3 Cell Phone

Guardian 3 Home Phone

Guardian 3 Home Phone Unlisted

Yes No

Guardian 3 Occupation

Guardian 3 Employer

Guardian 3 Work Phone

Guardian 3 Work Phone Extension

Guardian 4

Guardian 4 Relationship

Father Mother Legal Guardian Other

Guardian 4 Full Name

Guardian 4 Street Address 1

Address Line 1

Guardian 4 Street Address 2

Address Line 2

Guardian 4 City

City

Guardian 4 State

State

Guardian 4 Postal Code

Zip

Guardian 4 Email Address

Guardian 4 Cell Phone

Guardian 4 Home Phone

Guardian 4 Home Phone Unlisted

Yes No

Guardian 4 Occupation

Guardian 4 Employer

Guardian 4 Work Phone

Guardian 4 Work Phone Extension

Family Information

Languages

Languages spoken at home by the family (if other than English)

Please provide the names of other children living in the home as well as their grade levels and which school they attend.

Sibling 1 Name

Sibling 1 Grade

Sibling 1 School

Sibling 2 Name

Sibling 2 Grade

Sibling 2 School

Sibling 3 Name

Sibling 3 Grade

Sibling 3 School

Sibling 4 Name

Sibling 4 Grade

Sibling 4 School

Child Custody Agreement

Yes No Is there a child custody agreement? If so, please provide JRTI with a copy of the agreement.

Medical Information

Physician

Physician Phone

Dentist

Dentist Phone

Allergies or Drug Allergies

Please separate with a comma.

Medical Conditions

Please separate with a comma.

Medicine Received on a Regular Basis

Please separate with a comma.

Statement of Insurance

Boards of education, James Rumsey Technical Institute and technical instructors do not carry accident insurance on students. Accident insurance is for the personal protection of the individual.

All students attending James Rumsey Technical Institute are required to have accident insurance.

Insurance Company

Insurance Agent

Insurance Agent Phone

JRTI High School Student Data Form

Instructions

Student Information

School Information

Permissions

Guardians

Guardian 1

Guardian 2

Guardian 3

Guardian 4

Family Information

Medical Information

Statement of Insurance

All students attending James Rumsey Technical Institute are required to have accident insurance.

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