Enrollment Form - WCSD Portal - Walton County School District

0 downloads 228 Views 1MB Size Report
handicap, disability genetic information, or veteran status in its educational programs and activities. This includes bu
DOCUMENTS  R   EQUIRED  F   OR  S   CHOOL  R   EGISTRATION  Proof of Authorized Person to Enroll 

The  f ollowing  p   ersons  a   re  a   uthorized  t o  e   nroll  s  tudents:  ● ● ● ● ●

A  P   arent A  L   egal  g   uardian An  E   ligible  S   tudent A  g   randparent  w   ith  a    p   roperly  e   xecuted  P   ower of  A   ttorney An  a   dult  w   ho  h   as  a   ssumed  t  he  d   uties  a   nd responsibilities  o   f  a    p   arent  w   ith  r  espect  t  o  t  he student  s   eeking  e   nrollment

The  p   erson  a   uthorized  t o  e   nroll  s  hould  p   resent  o   ne  o   f  the  f ollowing:  ● ● ● ●

Driver’s  L   icense State  i dentification  c   ard Passport Other  o   fficial  p   hoto  i dentification

Documentation  N   eeded:  1. Student’s  b   irth  c  ertificate  o   r  F   ederal,  s  tate,  c  ounty,  o   r  s  chool  d   ocument  w   ith  d   ate  o   f  b   irth   (Examples  i nclude hospital­issued  b   irth  r  ecord;  m   ilitary  I .D.;  v  alid  d   river’s  l icense;  p   assport;  a   doption  r  ecord;  r  eligious  r  ecord;  s  chool  transcript;  o   r  a   ffidavit  o   f  a   ge  s  worn  b   y  p   arent/guardian  o   r  o   ther  a   uthorized  p   erson  a   ccompanied  b   y  a    c  ertificate  o   f  age  s  igned  b   y  a    l icensed,  p   racticing  p   hysician  w   hich  s  tates  t he  p   hysician  h   as  e   xamined  t he  c  hild  a   nd  b   elieves  t he  age,  a   s  s  tated  i n  t he  a   ffidavit,  i s  s  ubstantially  c  orrect.  2. Proof  o   f  r  esidence:   C   urrent  u   tility  b   ill  p   lus  o   ne  o   f  t he  f ollowing:   current  l ease/rental  a   greement;  r  ecent  i ncome  t ax return;  c  urrent  p   aycheck  s  tub  w   ith  c  urrent  a   ddress;  c  urrent  r  esidential  p   roperty  t ax  s  tatement  o   r  b   ill;  c  urrent  warranty  o   r  q   uitclaim  d   eed;  t hird  p   erson  a   ffidavit  o   f  r  esidency  (  refer  t o  W   alton  C   ounty  S   chool  D   istrict  ­   R   esidency  Affidavit);  c  urrent  h   omeowner’s  i nsurance  p   olicy.  3. Current  I mmunization  R   ecord  (  Georgia  I mmunization  F   orm  3   231)  o   r  m   edical  o   r  r  eligious  e   xemption. 4. If  n   ew  t o  G   eorgia  s  chools,  G   A  F   orm  3   300  –    C   ertificate  o   f  V   ision,  H   earing,  D   ental,  a   nd  N   utritional  S   creening. 5. Copy  o   f  s  tudent’s  s  ocial  s  ecurity  c  ard . Parents can sign a waiver in lieu of providing a Social Security card. 6. Previous  s  chool  r  ecords:   (  Grades  1   ­8  l atest  r  eport  c  ard)  (  Grades  9   ­12  l atest  t ranscript). 7. Legal  d   ocumentation  s  uch  a   s  g   uardianship  o   r  c  ustody  p   aperwork,  i f  a   pplicable.

No  s  tudent  s  hall  b   e  d   enied  e   nrollment  i n  t he  W   alton  C   ounty  P   ublic  S   chool  D   istrict  f or  d   eclining  t o  p   rovide  h   is  o   r  h   er  s  ocial  security  n   umber  o   r  f or  d   eclining  t o  a   pply  f or  s  uch  a    n   umber. 

As  r  equired  b   y  T   itle  V   I  o   f  t he  C   ivil  R   ights  A   ct  o   f  1   964,  S   ection  5   04  o   f  t he  R   ehabilitation  A   ct  o   f  1   973,  T   itle  I I  o   f  t he  A   mericans  w   ith  Disabilities  A   ct,  T   itle  I X  o   f  t he  E   ducation  A   mendments  o   f  1   972,  t he  A   ge  D   iscrimination  A   ct  o   f  1   975,  a   nd  t he  A   mericans  w   ith  D   isabilities  Act  o   f  1   990,  t he  W   alton  C   ounty  S   chool  D   istrict  d   oes  n   ot  d   iscriminate  o   n  t he  b   asis  o   f  r  ace,  c  olor,  g   ender,  r  eligion,   n   ational  o   rigin,  handicap,  d   isability  g   enetic  i nformation,  o   r  v  eteran  s  tatus  i n  i ts  e   ducational  p   rograms  a   nd  a   ctivities.   T   his  i ncludes  b   ut  i s  n   ot  l imited  t o  admissions,  e   ducational  s  ervices,  e   mployment,  a   nd  i n  a   ny  a   spect  o   f  t heir  o   perations.  F   or  a   dditional  i nformation  o   r  r  eferral  t o  t he  appropriate  s  ystem  c  oordinator,  c  ontact  t he  s  ystem  c  oordinator,  L   ance  Y   oung,  C   hief  H   uman  R   esources  O   fficer  a   t  2   00  D   ouble  S   prings  Church  R   oad,  M   onroe,  G   eorgia  3   0656,  o   r  a   t  7   70­266­4410 . 

,

Walton County School District Student Registration Packet

Reset Form

Version 17.10.17 OFFICE USE ONLY: Documentation

___GA Immunization

___Legal

___Birth Certificate

___GA Health Form

___Proof of Residency

___Social Security Card/Waiver

___Signed Records Release

Has student ever attended a Walton County School? _____No _____Yes School attended____________________

Section 1: Student Information Student’s Legal Name:____________________________________________________________________ (Last) (First) (Middle) (Preferred) Grade:______ Gender:______ Date of Birth:_________ Social Security:___________ Birth Place:_________ Race (must select at least one): ___American Indian or Alaska Native ___Asian Is this student currently in foster care? ____Yes ____No ___Black or African American What is the first date your child enrolled in grades K-12 in any United States _________ ___Native Hawaiian or Pacific Islander school, public or private, including the District of Columbia and Puerto Rico? ___White Is student of Hispanic/Latino ethnicity:___Yes ___No

Section 2: Primary Household Information Physical Address:_______________________________________________________________________ City:_____________________ State:___________ Zip:________ Home Phone:_____________________ Name of Parents/Guardians living in the household: Name:____________________________________ Relationship to student:_________________________ Cell Phone:______________ Work Phone:_____________ Email:_________________________________ Name:____________________________________ Relationship to student:_________________________ Cell Phone:______________ Work Phone:_____________ Email:_________________________________ Who has legal custody:___Both Parents ___Father ___Mother ___Other Legal documents provided: ___Y ___N Student lives with: ___Both Parents ___Father ___Mother ___Other ___Foster Parent Siblings attending Walton County School District: Name:_________________________ Grade:___ Name:_______________________________ Grade:___ Name:_________________________ Grade:___ Name:_______________________________ Grade:___

Section 3: Secondary Household Information Name of Parents/Guardians NOT living in the primary household: Name:____________________________________ Relationship to student:_________________________ Mailing Address:________________________________________________________________________ Home Phone:___________ Cell Phone:___________ Work Phone:__________ Email:_________________ Name:____________________________________ Relationship to student:_________________________ Mailing Address:________________________________________________________________________ Home Phone:___________ Cell Phone:___________ Work Phone:__________ Email:_________________

Registration Packet – Page 1

,

Section 4: Emergency Contact Information In the event that parents are unable to be contacted please list other people who are allowed to be contacted &/or pick up your child.

1.

Name:_______________________________ Relationship to student:________________________ Home Phone:________________ Cell Phone:____________________ Work Phone:______________ 2. Name:________________________________ Relationship to student:________________________ Home Phone:________________ Cell Phone:____________________ Work Phone:______________ 3. Name:_______________________________ Relationship to student:_________________________ Home Phone:________________ Cell Phone:____________________ Work Phone:______________ 4. Name:_______________________________ Relationship to student:_________________________ Home Phone:________________ Cell Phone:____________________ Work Phone:______________ List any additional people who are authorized to pick up your child: 1. ____________________________________ 2._______________________________________ 3. ____________________________________ 4._______________________________________

1.

List any people who MAY NOT pick up your child: ____________________________________ 2._______________________________________

Section 5: Previous School Information 1. Last School Attended & Address:____________________________________________Grade:_______ 2. Prior School & Address:__________________________________________________Grade:_______ Is your child currently on suspension or expulsion from this or another school system: ____Y ____N Reason for expulsion:____________________________________________________________________ School System:_________________________________________________Date:____________________ Has this student been adjudicated delinquent or convicted of murder, voluntary manslaughter, rape, aggravated sodomy, aggravated child molestation, aggravated battery or armed robbery?_____Y _____N If yes where did this offense occur?___________________________________________________________ Has your child ever received any of the following services? ___Special Education ___Early Intervention Program (EIP) ___English Language (ELL) ___Gifted Program ___POI/RTI ___504 ___Speech

Section 6: Student Residency This questionnaire is intended to address the McKinney-Vento Act 42 U.S.C. 11435. The answers to this residency information helps to determine the services the student may be eligible to receive. 1. Is your current address a temporary living arrangement? _____Y _____N 2. Is this temporary living arrangement due to loss of housing or economic hardship? _____Y _____N If you answered yes to the above questions please complete the remainder of this form. Where is student living? _____ Sharing housing of other persons due to loss of housing, economic hardship, or a similar reason. _____ Motel, hotel, campground, or similar setting due to lack of alternative adequate accommodations. _____ Emergency or transitional shelters or transitional housing shelter or agency. _____ Primary nighttime residence that is a place not designated for or ordinarily used as a regular sleeping accommodations for humans i.e. car, park, public spaces, abandoned buildings, or other. How long do you anticipate living at this location? ________________________________________________ Please indicate if your child participates or is eligible for any of the following (check all that apply): ___SSI ___TANF ___Medicaid ___Peachstate ___Amerigroup ___Food Stamps ___Wellcare ___Peachcare ___Free & Reduced Price Meals under Child Nutrition Program/School Nutrition Program.

Parent Signature: __________________________________________ Date: ________________ Registration Packet – Page 2

,

Home Language Survey Revised July, 2017 Dear Parent or Guardian: In order to provide your child with the best possible education, we need to determine how well he or she speaks and understands English. This survey assists school personnel in deciding whether your child may be a candidate for additional English language support. Final qualification for language support is based on the results of an English language assessment. Student Name (required information): _________________________________________________________________________ (Last)

(First)

(Middle)

Language Background (required information): 1. Which language does your child best understand and speak? ____________________________________________________________________ 2. Which language does your child most frequently speak at home? ____________________________________________________________________

3. Which language do adults in your home most frequently use when speaking with your child? ____________________________________________________________________ Language for School Communication (optional/not required): 4. In which language would you prefer to receive all school information? ____________________________________________________________________ _________________________________ Signature of Parent/Guardian

_________________ Date

School Personnel: Forward all Home Language Surveys to the Director of Federal Programs. District Office Use Only: Reviewed by Director of Federal Programs? ______ Referred for Screening? ______

,

Walton County School District

&

,

WALTON COUNTY SCHOOL DISTRICT “In Pursuit of Excellence”

Authorization to Release Records & Confidential Information Today’s Date: ______|______|______ mm

dd

yyyy

Information Being Requested By: School Name: Address: City, State, Zip:

Previous School Attended/Agency: PSA/Agency Name: Address: City, State, Zip:

Phone: Fax: WCSD Contact:

Phone: Fax: PSA/Agency Contact:

Student Name: DOB (mm/dd/yyyy):

SSN: Records Requested

Permanent Educational Record

Standardized Test Scores

RTI/POI Plan

Withdrawal Form with current grades

Screening & Health Information

Gifted Eligibility

Official transcript & recent report card

ESOL/ELL Record

Section 504 Plan

Social Security Number

Disciplinary Record (7th-12th) 9th Grade Enrollment Date (HS Only) GHSGT Test Results (HS Only) Length of Class Period/Number of Days per Week (HS Only)

Medical Report *Individualized Educational Program (IEP) *Psychological Evaluation

Birth Certificate Attendance Record Immunization Record Eye Ear & Dental Form

*Special Education Eligibility *Medicaid Card

Any other information that is vital to the student’s education. Regular Education SEND ANY REGULAR EDUCATION RECORDS TO: school and contact indicated above

*Exceptional Education - SEND ANY EXCEPTIONAL EDUCATION RECORDS TO: Director of Exceptional Education Walton County Board of Education 200 Double Springs Church Road, Monroe, GA., 30656 Fax: 770.266.4499

Parent Signature: __________________________________________ Date: ________________

Signature authorizes the school or agency listed above to release records & confidential information and/or communicate with the agency contact listed.

,

SCHOOL HEALTH INFORMATION CARD

(School Year 20___ to 20 ___)

Student # ___________ Grade ________ Teacher/HR ________________________________ Student: ________________________________ Gender: ___M ___F DOB: ____________ Address: ____________________________________________________________________ Health History ALLERGIES DIABETES SICKLE CELL DISEASE CANCER

___ YES ___ YES ___ YES ___ YES

___ NO ___ NO ___ NO ___ NO

PHYSICAL HANDICAPS SEIZURE DISORDER ASTHMA ADHD/ADD

___ YES ___ YES ___ YES ___ YES

___ NO ___ NO ___ NO ___ NO

If you answered yes to any of the above, please detail specifics in the space provided below along with any other physical or mental health issues which may be a concern at school. ___________________________________________________________________________ ___________________________________________________________________________ ___ Does your child have any condition that would limit physical education activities? List:___________________________________________________________________ ___ Does your child take any prescribed medications routinely? List: __________________________________________________________________ Do we have permission to complete Hearing and/or Vision Screenings on your child? ___ Yes ___ No List name(s) of school-aged siblings: 1. _________________________________ Grade/School _____|_________________ 2. _________________________________ Grade/School _____|_________________ 3. _________________________________ Grade/School _____|_________________ 4. _________________________________ Grade/School _____|_________________ Emergency Contact Information Parent/Guardian #1 ____________________________|_________________________|______________________ Last Name First Name Relation Home # _____________ Work # ______________ Cell # ______________ Parent/Guardian #2 ____________________________|_________________________|______________________ Last Name First Name Relation Home # _____________ Work # ______________ Cell # ______________ If parents/guardians cannot be reached, list two persons show will assume care of your child. Name ____________________________ Relationship _______________ Phone: ___________ Name ____________________________ Relationship _______________ Phone: ___________ Child’s Healthcare Provider: ______________________________________ Phone: ___________ I give permission to give my child (check all that apply) __Tylenol __Advil __Caladryl/Calamine Lotion __Benadryl Cream __Tums (or generic equivalent) according to label instructions; __cough drops according to label instructions. __Yes __No (Box MUST be checked for medication administration – Parent will be contacted prior to administration.) __Yes __No I understand that, if in the event of an emergency, I cannot be reached, the school will have my child transported to the hospital via the EMS/911 service to receive appropriate treatment.

Parent Signature: __________________________________________ Date: ________________

MEDIA CONSENT RELEASE Dear Parent/Guardian: On occasion, we are provided with the opportunity to publicize your child’s school. This may be a result of your child winning an award, participating in a school play, being part of an interesting class project and more. In addition, opportunities arise for us to promote student art and written work. However, your consent is needed so we can move forward in celebrating your child’s success. Please know that every situation where media are present is first approved by the district office. In addition to external media outlets, we also need your permission for promotional purposes related to the district web site, newsletters, brochures, social media and more. If you have any questions, please contact me at (770) 266-4542 or [email protected]. Thank you! Sincerely, Callen W. Moore Public Relations Officer The Walton County School District is authorized: (1) to photograph, audio record and video record my child in connection with classwork, school activities and team or club events whether individually or as part of a group; (2) to post a photograph, video recording and audio recording of my child on any school district related web site and social media platform; (3) to release information, recordings and photographs of my child to print media, television, radio and other news outlets in connection with my child’s achievements and/or participation in school and school district activities (e.g., Athletics, Anchor Club, Beta Club, FBLA, FCCLA, Safety Patrol); (4) to place my child’s photograph in the school yearbook as well as any school district, school or class programs or publications; and (5) to place my child’s photograph or school work (to include my child’s name) in a public location where it would be appropriate to display student work. (e.g., Board meetings, district events and school functions) Participants in the edTPA Georgia program or other teacher certification programs are authorized to videotape or record my child in connection with lessons or other class activities solely for use in training and/or evaluating the program participant. ( ) I DO authorize the activities described above. ( ) I DO NOT authorize the activities described above. I understand that this form is binding throughout the duration of my child’s enrollment in the Walton County School District and may be revoked at any time in writing. I certify that I am at least 18 years of age and have read and understood the above. Student’s Name (please print)

School/Grade

Signature of Parent/Guardian

Date