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New Student Application (Instance: new, Process: Student_Registration, Version: 1, Step: 1)

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	Instructions: Please enter student information. All fields in red require input. Click on "Send" button when complete.

Student Information

What school year are you applying for?
Enrollment Grade
For which grade range are you registering your child?

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
ZIP
Gender
Birth Date	MM/DD/YYYY
Birth City	As appears on Birth Certificate
Birth State/Country
U.S. Citizen
Nationality
Is there a language other than English spoken in the home?

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?

Home Language Survey

In what language(s) would your family prefer to communicate with the school
What language did your child learn first
Other - Please specify
What language does your child use the most at home
Other - Please specify
Other language spoken by your child
Other - Please specify
What languages are used in your home
What language do the adults use most frequently in the home?
Other - Please specify
Do you and your spouse read English?
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
How many years/months
What was the language of instruction
Has your child attended school in the United States
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?
Name of Parent(s)
Address
City
Zip Code

Home Phone
Student Cell Phone
School District of Residence
This is a residence that I
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

Previous Education

Current Grade
Did Child ever repeat a Grade?
If Yes, which grade(s)?
Expected Grade for new School Year

Student`s Previous Education (excluding preschool)
Name of School
Type of School
Name of District
County
School Address
City
State
ZIP
School Phone Number
Withdraw Date or last day attended	(mm/dd/yyyy)

Is this Student’s first time enrolled in an Ohio School?
Has the student ever attended Perry Local Schools?
If yes - Grades attended
Does your child receive any special education or related services?
	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
Home Language
Eyeglasses/ Contacts
Hearing Disabilty
Has had reading intervention

Has student been suspended or expelled from another school district?
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?

	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

Same as Student Address

Address

Address2

City

State

ZIP

Phone Number(s)

	Phone Type	Phone 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

	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

First Name

Last Name

Relationship to Student

Same as Student Address

Address

Address2

City

State

ZIP

Phone Number(s)

	Phone Type	Phone 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

Additional Contact (2)

Additional person whom we may contact in an emergency situation

First Name

Last Name

Relationship to Student

Same as Student Address

Address

Address2

City

State

ZIP

Phone Number(s)

	Phone Type	Phone 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

Additional Contact (3)

Additional person whom we may contact in an emergency situation

First Name

Last Name

Relationship to Student

Same as Student Address

Address

Address2

City

State

ZIP

Phone Number(s)

	Phone Type	Phone 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

Additional Contact (4)

Additional person whom we may contact in an emergency situation

First Name

Last Name

Relationship to Student

Same as Student Address

Address

Address2

City

State

ZIP

Phone Number(s)

	Phone Type	Phone Numbe
	-	-

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

Additional Contact (5)

Additional person whom we may contact in an emergency situation

First Name

Last Name

Relationship to Student

Same as Student Address

Address

Address2

City

State

ZIP

Phone Number(s)

	Phone Type	Phone 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

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
Special Conditions - Explain

Allergies
Allergies - Explain

Medications
Medications - Explain

Special Medication Care
Special Medication Care - Explain

Special Dietary
Special Dietary - Explain

Physical Limitations or Hearing Problems
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

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

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

Transportation Rules

Click for Info

Confirm

Attendance Policy

Click for Info

Confirm

Acceptable Use Policy

Click for Info

Confirm

Disclaimer - Residency of Students and Tuition

Click for Info

Confirm

Below is a checklist-please bring these items to your appointment

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