DO NOT PURGE

CHARLESTONCOUNTYSCHOOL DISTRICT STUDENT ENROLLMENT FORM

GRADES K-12

Enrollment Date / District / FullSchool Name:______
STUDENT INFORMATION / Grade / Age / Gender Male Female
Last Name / First Name / Middle Name

Race White African-American Hispanic American Indian Asian

(check one) African-American/American-Indian Hawaiian/Pacific-Islander White/Asian

White/African American White/American Indian Other:

Date of Birth / City/State Birth / SS# / --

(optional)

Previous Home Address / Present Phone
Student’s Mailing Address

StreetCityState Zip Code

Is your current residence temporary?  Yes  No, If yes, complete the student residency form.

Student’s Residence Address

StreetCityState Zip Code

Subdivision / Daycare No Yes / Name/Tel:
Previous School / First year in 9th grade (HS only)

Previous CCSD school if applicable ______

PARENT/GUARDIAN(S) INFORMATION

Last Name / First Name
Relationship
Employer
Work Phone / Ext. / Cell Phone
Home Address

Street/Apt#CityState Zip Code

Home Phone / Education: Last Grade (optional)
Email Address
Last Name / First Name
Relationship
Employer
Work Phone / Ext. / Cell Phone
Home Address

Street/Apt#CityState Zip Code

Home Phone / Education: Last Grade (optional)
Email Address

FAMILY INFORMATION

Student lives with (Name)

Relationship) Mother Father Step-Mother Step-Father Group Home: _____

(Check all that apply) Foster Mother Foster Father Legal Guardian

Other (please explain) ______

Note: If guardian, legal guardianshippapers must be provided and approved by the constituent district as part of cumulative records and if there is a legal custody agreement, documentation must be provided as part of cumulative records.

Please list any other children/siblings at this residence (even if not in school):

Name / Age / Grade / School
Name / Age / Grade / School
Name / Age / Grade / School

EMERGENCY INFORMATION

Medical: (i.e. asthma, diabetes, seizures, ADHD, ADD mental/physical conditions, allergies, insects, etc.)

Please List: ______

Medication(s)

______

EMERGENCY CONTACTS

Phone Numbers:

1.Name / Relationship / Home / Work / Cell
Address

StreetCityStateZip Code

2.Name / Relationship / Home / Work / Cell
Address

StreetCityStateZip Code

3.Name / Relationship / Home / Work / Cell
Address

StreetCityStateZip Code

Physician’s Name / Phone

ADDITIONAL INFORMATION

Has the student repeated a grade(s)?
Yes, grade(s)______
No
Did the student attend Kindergarten?
Yes No
Has the student ever been expelled?
Yes No
Grade expelled ______/ Does the student wear: (check all that apply)
Prescription glasses
Contact lens
Hearing aid
Other:______
None / Does the student have a (check all that apply)
504 Plan
Gifted/Talented designation
Migrant designation
NCLB Transfer
District approved transfer
Has the student ever received special education services(IEP)?
Yes
No / If student has an IEP please specify:
Resource
Inclusion
Self-Contained
Consultative / Area of Disability: (check all that apply)
LD Visually Impaired
ED Hearing Impaired
EMD OHI (medical condition)
TMD Orthopedic Impaired
PMD Speech/Language
Other:______

HOME LANGUAGE SURVEYEnglish Speakers of Other Language (ESOL)

1. What language did your child learn when he/she first began to speak?
(If the answer is English, please disregard questions 2 , 3 & 4)
2. In which language do you prefer to receive correspondence from the school?
3. If your child was not born in the USA, in what country was he/she born?
4. What date did your child first begin school in the United States?

TRANSPORTATION

Student will ride school bus in the morning Yes NoStudent will ride school bus in the afternoon Yes No

Other: / AM Bus # / PM Bus # / Car rider: AM Yes No PM Yes No

(Parent/Day Care Bus/Van/Walker)

All information on this form is correct to the best of my knowledge.

Parent/Guardian Signature: ______Date: ______

THIS SPACE FOR OFFICE USE ONLYCumulative File Reviewed ______

2 Proofs of Residence ______Legal Guardianship papers ______Homeroom Assigned ______

Social Security Card ______Records Requested ______Teacher Assigned ______

State Birth Certificate ______Enrollment Date ______Bus Number/Car Rider ______

SC Immunization ______Military ______Media release ______

(Put your school information in this space)

REQUEST FOR RECORDS

Student’s Full Name: ______Date of Birth: ______

Has enrolled in our school.

Please forward the following information:

____Transcript____ Attendance Record____ IEP/Due process folder

____ Standardized test scores____ Psychological ____ 504

____ Withdrawal Form____ Immunization certificate____ IGP/Career Assessment

____ CCSD permanent file____Birth Certificate____ Social Security

____ Discipline Record____ Other ______

____ Complete numeric grades to date of withdrawal

I hereby authorize CharlestonCountySchool District to receive all school records regarding my child. My signature gives CharlestonCountySchool District permission to consider and use this information for appropriate placement.

Previous School Attended

StreetCityStateZip Code

School Phone NumberContact PersonSchool Fax Number

Parental permission is no longer required when authorized school personnel request records. (Family Education Act, Final Rule on Education Records. Federal registration, June 17, 1976 Vol. 41 No. 118 Page 24673). It states that the school officials including teachers within the educational institutions and officials of other school systems in which the student may intend to enroll, may receive school records without written consent for such releases.

Parent/Guardian Signature (Optional): ______Date: ______

Relationship to Student: ______

School Designee: ______Date: ______

DATE:1st Attempt ______2nd Attempt ______3rd Attempt ______

student enrollment form - revised: 4/21/081