School address and phone: ... Home Phone: ... STUDENT SERVICES. Does your child have a current IEP? ______Yes. ______No.
BUCKEYE VALLEY LOCAL SCHOOL DISTRICT PUPIL ENROLLMENT FORM STUDENT INFORMATION Name: _________________________________________________________________ Last First Middle
___Male
___Female
Address: _____________________________________________________________________________________ #Road/Street PO Box # City State Zip Telephone: ______________________ Authority for Date of Birth:
Date of Birth: _______________
______Birth Certificate ______Passport
City of Birth: __________________
______Baptismal Certificate
School District of Residency: _____________________________________________________________________ Proof of Residency:
Anticipated date of entrance into BV Schools: ____________________
Current Grade Level: _____________
ETHNICITY and RACE (please complete one in each, A AND B.) A. Ethnicity (choose one)
B. Race (choose one or more, regardless of ethnicity)
______Hispanic/Latino ______Not Hispanic/Latino
______American Indian or Alaskan Native ______Asian ______Black or African American ______Native Hawaiian or other Pacific Islander ______White PREVIOUS SCHOOL DISTRICT INFORMATION
Previous School District and school: ________________________________________________________ School address and phone: _______________________________________________________________ Dates attended: ___________________ Teacher Name: __________________________________ PARENT/GUARDIAN INFORMATION Person with whom student is residing:
Revised 11/2012
______Both parents ______Father/Stepmother ______Mother only ______Grandparent
______Mother/Stepfather ______Father only ______Guardian ______Other
Check any that apply:
______Mother deceased ______Parents separated
______Father deceased ______Parents divorced
***Please note that if there is any custody arrangement/court order we require the official stamped court paperwork on file. Court paperwork provided with this packet: _____Yes _____No _____N/A Father: ______________________________
Mother: _______________________________
Address: _____________________________
Address: _______________________________
_____________________________
_______________________________
City, State, Zip
City, State, Zip
Employer: ____________________________
Employer: ______________________________
Home Phone: _________________________
Home Phone: ____________________________
Work Phone: __________________________
Work Phone: ____________________________
Cell Phone: ___________________________
Cell Phone: ______________________________
Email: _______________________________
Email: __________________________________
Please list below any step-parent or other guardian who is allowed to pick-up your student: Stepfather/Guardian: ____________________
Stepmother/Guardian: _____________________
Address: ______________________________
Address: ________________________________
______________________________
________________________________
Home Phone: __________________________
Home Phone: ____________________________
Work Phone: ___________________________
Work Phone: _____________________________
Cell Phone: ____________________________
Cell Phone: ______________________________
***Legal Guardians must fill out the “Statement of Guardianship” form. If you are self-supporting, you must fill out the “18 Year Old Self-Supporting” form. Please list below any siblings who attend BV Schools: Name: _________________________ Grade: ____
Name: ______________________ Grade: ____
Name: _________________________ Grade: ____
Name: ______________________ Grade: ____
LANGUAGE Has your child been identified as an English Language Learner (ELL)? _______ What language did your child learn when he or she first began to talk? _______________________ What language does your child use at home? ____________________ What language do you use when speaking to your child? ____________________ What language is most often spoken by the adults at home? __________________ Does anyone in your home read English? _________________________________ Revised 11/2012
Country of Birth: ___________________ Year entered US Schools: ___________ Immigrant Youth? __________________ OTHER INFORMATION Has your child ever been enrolled in Buckeye Valley schools? ______________ If yes, when: __________________ What building did they attend? ________________________________ Has your child ever been suspended or expelled from another school?
_____Yes _____No
STUDENT SERVICES Does your child have a current IEP?
______Yes
______No
Does your child have a current 504 Plan?
______Yes
______No
Is your child identified as gifted?
______Yes
______No
SIGNATURE I CERTIFY ON THIS DATE THAT THE INFORMATION IS CORRECT AND COMPLETE AND THAT I AM THE CUSTODIAL PARENT. I UNDERSTAND THAT ANY CHANGES IN THE ABOVE INFORMATION MUST BE REPORTED TO THE SCHOOL OFFICE. I FURTHER UNDERSTAND THAT FALSIFYING THIS INFORMATION COULD RESULT IN THE IMMEDIATE REMOVAL OF MY CHILD FROM THE BUCKEYE VALLEY LOCAL SCHOOL DISTRICT. ______________________________________________________________ Signature Date ______________________________________________________________ Enrolling Secretary Signature Date
