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Student Information
What school year are you applying for?
-
2019/2020
2020/2021
Enrollment Grade
-
PS
K
1
2
3
4
5
6
7
8
9
10
11
12
For which grade range are
you registering your child?
-
Pre-K & K
Grade 1, 2, or 3
Grade 4 - 12
Student Legal First Name
As appears on Birth Certificate
Student Legal Middle Name
As appears on Birth Certificate
Student Legal Last Name
As appears on Birth Certificate
Called Name
Address
Address 2
City
County of Residence
State
OHIO
ALABAMA
ALASKA
AMERICAN SAMOA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FEDERATED STATES OF MICRONESIA
FLORIDA
GEORGIA
GUAM
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARSHALL ISLANDS
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
NORTHERN MARIANA ISLANDS
OKLAHOMA
OREGON
PALAU
PENNSYLVANIA
PUERTO RICO
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGIN ISLANDS
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
ZIP
Gender
-
MALE
FEMALE
Birth Date
MM/DD/YYYY
Birth City
As appears on Birth Certificate
Birth State/Country
U.S. Citizen
-
NO
YES
Nationality
Is there a language other than
English spoken in the home?
-
NO
YES
Ethnic Background
Please Check at least one
*one selection is required.
A-Asian
B-Black or African American
P-Native Hawaiian or Other Pacific Islander
I-American Indian or Alaska Native
W-White
Is your child Hispanic/Latino?
-
N - No, the student is not Hispanic/Latino
Y - Yes, the student is Hispanic/Latino
Home Language Survey
In what language(s) would your family prefer to communicate with the school
What language did your child learn first
-
English
Akan
Albanian
Amharic
Arabic
Aremenian
Bambara
Basaa
Bengali
Bosnian
Bulgarian
Burmese
Central Khmer
Chinese
Croatian
Danish
Dinka
Ewe
Filipino
French
Fulah
Georgian
German
Greek
Gujarati
Hebrew
Hindi
Hmong
Hungarian
Igbo
Indonesian
Italian
Japanese
Karen
Kikuyu
Kinyarwanda
Korean
Krahn
Krio
Kurdish
Lao
Lithuanian
Louisiana Creole French
Maay
Macedonian
Malay
Malayalam
Mandingo
Marathi
Mongolian
Navajo
Nyanja
Oromo
Panjabi
Persian
Polish
Portuguese
Pushto
Romanian
Russian
Serbian
Shona
Sinhala
Somali
Spanish
Swahili
Swedish
Tagalog
Tamil
Telugu
Thai
Tigrinya
Tswana
Turkish
Twi
Ukranian
Urdu
Uzbek
Vietnamese
Wolof
Yoruba
Other - please specify
Other - Please specify
What language does your child use the most at home
-
English
Akan
Albanian
Amharic
Arabic
Aremenian
Bambara
Basaa
Bengali
Bosnian
Bulgarian
Burmese
Central Khmer
Chinese
Croatian
Danish
Dinka
Ewe
Filipino
French
Fulah
Georgian
German
Greek
Gujarati
Hebrew
Hindi
Hmong
Hungarian
Igbo
Indonesian
Italian
Japanese
Karen
Kikuyu
Kinyarwanda
Korean
Krahn
Krio
Kurdish
Lao
Lithuanian
Louisiana Creole French
Maay
Macedonian
Malay
Malayalam
Mandingo
Marathi
Mongolian
Navajo
Nyanja
Oromo
Panjabi
Persian
Polish
Portuguese
Pushto
Romanian
Russian
Serbian
Shona
Sinhala
Somali
Spanish
Swahili
Swedish
Tagalog
Tamil
Telugu
Thai
Tigrinya
Tswana
Turkish
Twi
Ukranian
Urdu
Uzbek
Vietnamese
Wolof
Yoruba
Other - please specify
Other - Please specify
Other language spoken by your child
-
English
Akan
Albanian
Amharic
Arabic
Aremenian
Bambara
Basaa
Bengali
Bosnian
Bulgarian
Burmese
Central Khmer
Chinese
Croatian
Danish
Dinka
Ewe
Filipino
French
Fulah
Georgian
German
Greek
Gujarati
Hebrew
Hindi
Hmong
Hungarian
Igbo
Indonesian
Italian
Japanese
Karen
Kikuyu
Kinyarwanda
Korean
Krahn
Krio
Kurdish
Lao
Lithuanian
Louisiana Creole French
Maay
Macedonian
Malay
Malayalam
Mandingo
Marathi
Mongolian
Navajo
Nyanja
Oromo
Panjabi
Persian
Polish
Portuguese
Pushto
Romanian
Russian
Serbian
Shona
Sinhala
Somali
Spanish
Swahili
Swedish
Tagalog
Tamil
Telugu
Thai
Tigrinya
Tswana
Turkish
Twi
Ukranian
Urdu
Uzbek
Vietnamese
Wolof
Yoruba
Other - please specify
Other - Please specify
What languages are used in your home
What language do the adults use
most frequently in the home?
-
English
Akan
Albanian
Amharic
Arabic
Aremenian
Bambara
Basaa
Bengali
Bosnian
Bulgarian
Burmese
Central Khmer
Chinese
Croatian
Danish
Dinka
Ewe
Filipino
French
Fulah
Georgian
German
Greek
Gujarati
Hebrew
Hindi
Hmong
Hungarian
Igbo
Indonesian
Italian
Japanese
Karen
Kikuyu
Kinyarwanda
Korean
Krahn
Krio
Kurdish
Lao
Lithuanian
Louisiana Creole French
Maay
Macedonian
Malay
Malayalam
Mandingo
Marathi
Mongolian
Navajo
Nyanja
Oromo
Panjabi
Persian
Polish
Portuguese
Pushto
Romanian
Russian
Serbian
Shona
Sinhala
Somali
Spanish
Swahili
Swedish
Tagalog
Tamil
Telugu
Thai
Tigrinya
Tswana
Turkish
Twi
Ukranian
Urdu
Uzbek
Vietnamese
Wolof
Yoruba
Other - please specify
Other - Please specify
Do you and your spouse read English?
-
NO
YES
Total number of months in attendance
in US School system
1 year = 9 months
In what country was your child born
Has your child ever received formal education outside of the united States
-
NO
YES
How many years/months
What was the language of instruction
-
English
Albanian
Amharic
Arabic
Cambodian
Cantonese
Creole (Fr)
German
Hmong
Japanese
Korean
Laotian
Navajo
Portuguese
Romanian
Russian
Serbo Croat
Somali
Spanish
Tagalog
Trygriyan
Ukranian
Vietnamese
Other - please specify
Has your child attended school in the United States
-
NO
YES
Date Student first enrolled in a US School
(MM/DD/YYYY)
Additional Information
Student Residence / Home
Is the Student's address
the same as the Parents?
-
NO
YES
Name of Parent(s)
Address
City
Zip Code
Home Phone
Student Cell Phone
School District of Residence
This is a residence that I
-
Own
Rent
Live with another family
Homeless shelter
Unsheltered
Abandoned
other - please explain
Please explain
When did your child first attend a school in the United States
I understand that if the District determines that the above address is not my legal residence for purposes of enrollment of my child(ren) in school in this District, that I may be subject to legal action and the payment of any tuition charges for the period of time that my child was enrolled as a non-resident student.
Confirm
-
I acknowledge that I have read and understand the policy
Previous Education
Current Grade
-
N/A
Pre-K
K
1
2
3
4
5
6
7
8
9
10
11
12
Did Child ever repeat a Grade?
-
NO
YES
If Yes, which grade(s)?
Expected Grade for new School Year
-
K
1
2
3
4
5
6
7
8
9
10
11
12
Student`s Previous Education
(excluding preschool)
Name of School
Type of School
-
Preschool
Public
Private
Community
Charter/Digital
Home
Name of District
County
School Address
City
State
-
OHIO
ALABAMA
ALASKA
AMERICAN SAMOA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FEDERATED STATES OF MICRONESIA
FLORIDA
GEORGIA
GUAM
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARSHALL ISLANDS
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
NORTHERN MARIANA ISLANDS
OKLAHOMA
OREGON
PALAU
PENNSYLVANIA
PUERTO RICO
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGIN ISLANDS
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
ZIP
School Phone Number
Withdraw Date or last day attended
(mm/dd/yyyy)
Is this Student’s first time enrolled in an Ohio School?
-
NO
YES
Has the student ever attended Perry Local Schools?
-
NO
YES
If yes - Grades attended
Does your child receive any special education or related services?
-
NO
YES
Please provide IEP or
ETR to School Office
What services are they receiving?
(learning or cognitive disabilities, multiple disabilities, emotional disturbance, hearing or visual impairment, reading intervention, Speech/Language/Hearing, OT/PT services, 504 Plan, or others...)
Identified for Gifted Education
Please Check All that Apply
Enrichment Services
Math
Reading
Other
Other - Please specify
Other Vital Data
Please Check All that Apply
Limited English Proficient Services
-
NO
YES
Home Language
-
English
Akan
Albanian
Amharic
Arabic
Aremenian
Bambara
Basaa
Bengali
Bosnian
Bulgarian
Burmese
Central Khmer
Chinese
Croatian
Danish
Dinka
Ewe
Filipino
French
Fulah
Georgian
German
Greek
Gujarati
Hebrew
Hindi
Hmong
Hungarian
Igbo
Indonesian
Italian
Japanese
Karen
Kikuyu
Kinyarwanda
Korean
Krahn
Krio
Kurdish
Lao
Lithuanian
Louisiana Creole French
Maay
Macedonian
Malay
Malayalam
Mandingo
Marathi
Mongolian
Navajo
Nyanja
Oromo
Panjabi
Persian
Polish
Portuguese
Pushto
Romanian
Russian
Serbian
Shona
Sinhala
Somali
Spanish
Swahili
Swedish
Tagalog
Tamil
Telugu
Thai
Tigrinya
Tswana
Turkish
Twi
Ukranian
Urdu
Uzbek
Vietnamese
Wolof
Yoruba
Other - please specify
Eyeglasses/ Contacts
Hearing Disabilty
Has had reading intervention
Has student been suspended or expelled from another school district?
-
NO
YES
Provide date and district involved:
Parent/Guardian/Custody Information
If there are any court documents for this student, you are required by law
to provide us with a complete copy of the most current court documentation at time of enrollment.
Are there any court orders concerning this child?
-
NO
YES
Please Check All That Apply:
Biological Parents Married
Biological Parents Divorced
Shared Parenting
Biological Parents Separated
Court Placement
Father Deceased
Mother Deceased
Biological Parents Never Married
Foster Placed
Primary Contact
Primary contact is the person (or persons) responsible for the regular care of the student and to whom the school may send school-related correspondence. The primary contact is also the first point of contact for the school in the unlikely event that the child is injured or becomes ill while at school. In general, the Primary Contact refers to the parent(s) or guardian(s) of the student and will likely be duplicated from the Family Data Section.
First Name
Last Name
Relationship to Student
-
MOTHER
FATHER
STEP MOTHER
STEP FATHER
COURT/CSB CONTACT
GUARDIAN
EMERGENCY CONT.
RELATIVE
OTHER
Same as Student Address
Address
Address2
City
State
-
OHIO
ALABAMA
ALASKA
AMERICAN SAMOA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FEDERATED STATES OF MICRONESIA
FLORIDA
GEORGIA
GUAM
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARSHALL ISLANDS
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
NORTHERN MARIANA ISLANDS
OKLAHOMA
OREGON
PALAU
PENNSYLVANIA
PUERTO RICO
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGIN ISLANDS
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
ZIP
Phone Number(s)
Phone Type
Phone Number
-
-
-
Home number
Cell number
Work number
Pager number
To add row click on + to delete select checkbox for row and click on -
Place of Work
Address of Work
E-mail Address
Addl. E-mail Address
Type of Contact
Please Check All that Apply
Legal Guardian
Has Legal Custody of Child
Medical Auth Contact
Available at Work
Living with Student
Willing to Volunteer
Copied on Correspondence
In the event that the school is unable to reach the Primary Contact, parents are encouraged to provide at least one and up to 5 additional contacts whom the school may call in the unlikely event that this student is injured or becomes ill while at school.
IMPORTANT NOTE: Primary and additional contacts are the only persons authorized to pick up a child from school. As a result, please create an additional contact below for those individuals whom you authorize to pick up your child from school in place of a parent or legal guardian.
A photo ID will be required at the time of pick-up.
Additional Contact (1)
Additional person whom we may contact in an emergency situation
Add Additional Contact (1)
First Name
Last Name
Relationship to Student
-
MOTHER
FATHER
STEP MOTHER
STEP FATHER
COURT/CSB CONTACT
GUARDIAN
EMERGENCY CONT.
RELATIVE
OTHER
Same as Student Address
Address
Address2
City
State
-
OHIO
ALABAMA
ALASKA
AMERICAN SAMOA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FEDERATED STATES OF MICRONESIA
FLORIDA
GEORGIA
GUAM
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARSHALL ISLANDS
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
NORTHERN MARIANA ISLANDS
OKLAHOMA
OREGON
PALAU
PENNSYLVANIA
PUERTO RICO
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGIN ISLANDS
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
ZIP
Phone Number(s)
Phone Type
Phone Number
-
-
-
Home number
Cell number
Work number
Pager number
To add row click on + to delete select checkbox for row and click on -
Place of Work
E-mail Address
Type of Contact
Please Check All that Apply
Legal Guardian
Has Legal Custody of Child
Medical Auth Contact
Available at Work
Living with Student
Willing to Volunteer
Delete this Contact (1)
Additional Contact (2)
Additional person whom we may contact in an emergency situation
Add Additional Contact (2)
First Name
Last Name
Relationship to Student
-
MOTHER
FATHER
STEP MOTHER
STEP FATHER
COURT/CSB CONTACT
GUARDIAN
EMERGENCY CONT.
RELATIVE
OTHER
Same as Student Address
Address
Address2
City
State
-
OHIO
ALABAMA
ALASKA
AMERICAN SAMOA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FEDERATED STATES OF MICRONESIA
FLORIDA
GEORGIA
GUAM
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARSHALL ISLANDS
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
NORTHERN MARIANA ISLANDS
OKLAHOMA
OREGON
PALAU
PENNSYLVANIA
PUERTO RICO
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGIN ISLANDS
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
ZIP
Phone Number(s)
Phone Type
Phone Number
-
-
-
Home number
Cell number
Work number
Pager number
To add row click on + to delete select checkbox for row and click on -
Place of Work
E-mail Address
Type of Contact
Please Check All that Apply
Legal Guardian
Has Legal Custody of Child
Medical Auth Contact
Available at Work
Living with Student
Willing to Volunteer
Delete this Contact (2)
Additional Contact (3)
Additional person whom we may contact in an emergency situation
Add Additional Contact (3)
First Name
Last Name
Relationship to Student
-
MOTHER
FATHER
STEP MOTHER
STEP FATHER
COURT/CSB CONTACT
GUARDIAN
EMERGENCY CONT.
RELATIVE
OTHER
Same as Student Address
Address
Address2
City
State
-
OHIO
ALABAMA
ALASKA
AMERICAN SAMOA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FEDERATED STATES OF MICRONESIA
FLORIDA
GEORGIA
GUAM
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARSHALL ISLANDS
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
NORTHERN MARIANA ISLANDS
OKLAHOMA
OREGON
PALAU
PENNSYLVANIA
PUERTO RICO
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGIN ISLANDS
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
ZIP
Phone Number(s)
Phone Type
Phone Number
-
-
-
Home number
Cell number
Work number
Pager number
To add row click on + to delete select checkbox for row and click on -
Place of Work
E-mail Address
Type of Contact
Please Check All that Apply
Legal Guardian
Has Legal Custody of Child
Medical Auth Contact
Available at Work
Living with Student
Willing to Volunteer
Delete this Contact (3)
Additional Contact (4)
Additional person whom we may contact in an emergency situation
Add Additional Contact (4)
First Name
Last Name
Relationship to Student
-
MOTHER
FATHER
STEP MOTHER
STEP FATHER
COURT/CSB CONTACT
GUARDIAN
EMERGENCY CONT.
RELATIVE
OTHER
Same as Student Address
Address
Address2
City
State
-
OHIO
ALABAMA
ALASKA
AMERICAN SAMOA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FEDERATED STATES OF MICRONESIA
FLORIDA
GEORGIA
GUAM
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARSHALL ISLANDS
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
NORTHERN MARIANA ISLANDS
OKLAHOMA
OREGON
PALAU
PENNSYLVANIA
PUERTO RICO
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGIN ISLANDS
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
ZIP
Phone Number(s)
Phone Type
Phone Numbe
-
-
-
Home number
Cell number
Work number
Pager number
To add row click on + to delete select checkbox for row and click on -
Place of Work
E-mail Address
Type of Contact
Please Check All that Apply
Legal Guardian
Has Legal Custody of Child
Medical Auth Contact
Available at Work
Living with Student
Willing to Volunteer
Delete this Contact (4)
Additional Contact (5)
Additional person whom we may contact in an emergency situation
Add Additional Contact (5)
First Name
Last Name
Relationship to Student
-
MOTHER
FATHER
STEP MOTHER
STEP FATHER
COURT/CSB CONTACT
GUARDIAN
EMERGENCY CONT.
RELATIVE
OTHER
Same as Student Address
Address
Address2
City
State
-
OHIO
ALABAMA
ALASKA
AMERICAN SAMOA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FEDERATED STATES OF MICRONESIA
FLORIDA
GEORGIA
GUAM
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARSHALL ISLANDS
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
NORTHERN MARIANA ISLANDS
OKLAHOMA
OREGON
PALAU
PENNSYLVANIA
PUERTO RICO
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGIN ISLANDS
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
ZIP
Phone Number(s)
Phone Type
Phone Number
-
-
-
Home number
Cell number
Work number
Pager number
To add row click on + to delete select checkbox for row and click on -
Place of Work
E-mail Address
Type of Contact
Please Check All that Apply
Legal Guardian
Has Legal Custody of Child
Medical Auth Contact
Available at Work
Living with Student
Willing to Volunteer
Delete this Contact (5)
District-wide Notification System
This phone number will be used for attendance phone calls, district news and emergency notifications.
Notification Phone Number
Notification Phone Number 2
Notification Email Address
Notification Email Address 2
Child Medical Care
Primary Medical Contact(s)
Primary Physician
Primary Physician Last Name
Primary Physician First Name
Primary Physician Phone
Dentist
Dentist Last Name
Dentist First Name
Dentist Phone
Medical Specialist
Medical Specialist Last Name
Medical Specialist First Name
Medical Specialist Phone
Preferred Hospital / ER
Preferred Hospital Name
Hospital / ER Phone
Medical Conditions and Special Care
Please provide information about medical conditions your child has, special care that may be required for your child while at school or school events, and/or medications your child takes. This information, which will remain confidential, will be helpful to the school staff in the unlikely event that your child is involved in an emergency while at school or at a school-sponsored event.
Special Conditions
-
NO
YES
Special Conditions - Explain
Allergies
-
NO
YES
Allergies - Explain
Medications
-
NO
YES
Medications - Explain
Special Medication Care
-
NO
YES
Special Medication Care - Explain
Special Dietary
-
NO
YES
Special Dietary - Explain
Physical Limitations or Hearing Problems
-
NO
YES
Physical Limits,
Hearing Problems
- Explain
Date(s) of hospitilizations and reason(s) why child was hospitalized (each time)
List of diseases child had to date
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Check here if special care or administration of medication may be required at school. Additional requests for information will be sent home by the district medical staff.
Child Care Provider
Child Care Provider Information
Provider Name
Relationship
Address
City
ZIP
Phone
Transportation
Do you need transportation to and from School
-
NO
YES
CONSENT - Part I or Part II must be completed
EMERGENCY MEDICAL AUTHORIZATION Purpose - To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while under school authority when parents or guardians cannot be reached. This information may be shared with the educational team to best meet your child’s needs.
GRANT CONSENT
PART I - TO GRANT CONSENT
In the event that reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by above-named doctor, or, in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinion of two (2) other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.
REFUSAL TO CONSENT
PART II - REFUSAL TO CONSENT
I do NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the school authorities to take the following action:
Please explain
Annual Parent Notifications & Consents, valid for above selected school year
Media Release
Click for Info
Choose Media Release
-
I grant permission
I do not grant permission
Transportation Rules
Click for Info
Confirm
-
I acknowledge that I have read and understand the rules
Attendance Policy
Click for Info
Confirm
-
I acknowledge that I have read and understand the policy
Acceptable Use Policy
Click for Info
Confirm
-
I acknowledge that I have read and understand the policy
Disclaimer - Residency of Students and Tuition
Click for Info
Confirm
-
I acknowledge that I have read and understand the policy.
Below is a checklist-please bring these items to your appointment
For all Grades
Student`s Birth Certificate
- Bring a state-issued, certified birth certificate for Student. A copy will be made for school records at the time of registration. If enrolling in Kindergarten, the child must be five years old on or before August 1st of the current school year.
Student`s Social Security card
- Bring the Student`s Social Security Card or evidence of Social Security Number, e.g. tax return showing child.
Verified Parent/Guardian Identification
- Please bring a copy of a valid photo ID of the custodial parent/guardian such as a driver`s license.
Proof of Residency
If you own:
Current Utility Bill with Service Address
If you rent:
Rent or Lease Agreement with Landlord’s Contact Information & Current Utility Bill with Service Address
Immunization Record
- Bring a copy of your child`s immunization records
Click here to download Immunization form
Current Transcript
(Recommended)
Custody Papers
(If Applicable) - Bring the most recent court orders allocating parental rights and responsibilities or other documents allocating custody or guardianship, if applicable. This FULL document must be a
certified copy
of a judgment entry, court order, or decree signed by a judge and filed with the clerk of courts.
Student`s IEP/ETR/504 Plan
(If Applicable) - Please bring a copy of your child`s IEP, ETR, or 504 plans, if applicable.
Gifted Test Scores
(If Applicable) - Please bring a copy of the Student`s Gifted Test Scores, if applicable.
Home Language Survey
(If Applicable) - Please fill out this form if a language other than English is spoken in the home.
Click here to download Home Language Survey
Permission for Release of Records
(If Applicable)
Click here to download Permission for Release of Records form
Free And Reduced Lunch Application
(If Applicable)
Click here to download a Free and Reduced Lunch Application
After completion, please schedule an enrollment appointment when prompted to do so, or contact the Registration Department at 330-915-5300.
Signature
I hereby certify that the statements and information in this application form are true and correct to the best of my knowledge.
Please enter your full name