RRPS S.A.F.E. Program Registration & Wait List

2024-2025 Pre-Registration

This form is to apply for our S.A.F.E. Program.

We will email you if your student has a confirmed spot or if they have been placed on our Wait List.

Please do not provide payment until you receive a confirmation email.

Payments for unconfirmed registrations will not be refunded.

Please submit only one application per child. Multiple submissions will be deleted

RIO RANCHO PUBLIC SCHOOLS - 500 Laser Rd NE - Rio Rancho, NM 87124

Is either Parent
or Guardian an
RRPS Employee *

School *

SAFE Coordinator *

RRPS Employee
S.A.F.E. SERVICES * 🛈

S.A.F.E. SERVICES *

Pay Frequency? *

Date Applied

Student Information

Last Name *

First Name *

Gender *

DOB * +

Email Address *

If you do not

have a Student

ID # or a

Teacher enter

n/a in the field.

Student ID # *

Teacher *

Grade in Fall *

Pre-K &

Kinder not

availalble

for SVE.

Phone *

Do you qualify for free
& reduced lunches for
the school year of this
S.A.F.E. application? *

Do you have another
student or students in SAFE? *

Names of other Student(s) in SAFE. *

HEALTH HISTORY

Student has (check all that apply) *

Allergies (Check all that apply) *

Food Allergies (list) *

0/255 characters

Other Allergies (list) *

0/255 characters

Health Conditions (Check all that apply) *

High Blood Pressure *

yes

no

Cardiovascular (list): Cardiovascular (list):

Long Term Medications (list) *

0/90 characters

Any other health conditions (list) *

Yes

Emergency Services Consent:
I agree, In case of an emergency involving my child AND I Cannot Be Reached, I understand emergency medical services
will be contacted and my child may be transported to the following provider / hospital for emergency medical care. *

1st PARENT / GUARDIAN INFORMATION

1st Parent / Guardian's Full Name *

1st Parent / Guardian's Ph *

(1st) Authorized to
pick up children *

Yes

No

If No, please provide a current

custody order to RRPS Staff.

Street (parent1) *

City (parent1) *

State (parent1) *

Zip (parent1) *

Phone (parent1) *

1st Parent / Guardian's Email *

1st Parent / Guardian's Employer

Enter 2nd Parent
/ Guardian Info *

Yes

No

Yes

I have read & agree
to the terms of the
S.A.F.E. Handbook (download)

*

2nd PARENT/GUARDIAN INFORMATION

2nd Parent / Guardian's Full Name *

2nd Parent / Guardian's Phone *

(2nd) Authorized to
pick up children *

Yes

No

If No, it is the responsibility
of the parent to provide the
most recent custody order
to the district.

2nd Parent / Guardian's Email

2nd Parent / Guardian's Employer

Phone (parent2) *

Street (parent2) *

City (parent2) *

State (parent2) *

Zip (parent2) *

With whom does your child reside
(check all that apply) *

Parent / Guardian 1

Parent / Guardian 2

Please describe any special custody arrangements

EMERGENCY CONTACT & AUTHORIZED PICKUP INFORMATION

** List three contacts who must live in Rio Rancho or Albuquerque (NOT THE PARENTS/GUARDIANS) **

These are individuals who are available during the hours that your child(ren) attend SAFE

and are authorized to pick up your child(ren).

1. Contact Full Name *

1. Phone *

1. Relation to child *

2. Contact Full Name

2. Phone

2. Relation to child

3. Contact Full Name

3. Phone

3. Relation to child

4. Contact Full Name

4. Phone

4. Relation to child

5. Contact Full Name

5. Phone

5. Relation to child

test mode

Not Applicable	IEP (disability)	Student Medical Plan (asthma, diabetes, etc..)
Behavior Intervention Plan	504 Plan (Special Accommodations)

Not Applicable	Seasonal Allergies
Food Allergies	Other Allergies
Has EpiPen prescription

Not Applicable	ADD / ADHD	Asthma (needs inhaler at SAFE)	Bladder / GU	Cancer
Congenital / Genetic	Dental/Oral	Dermatologic / Skin	Diabetes (Type 1)	Diabetes (Type 2)
Ear / Nose / Throat	Eating Disorder	Endocrine Other than Diabetes	Has EpiPen prescription	Hearing Impairment
Hematology / Bleeding Disorders	Migraines	Musculoskeletal	Psychiatric	Pulmonary (Other than Asthma)
Seizures	Stomach / GI	Wears glasses / contacts