Plain Local School District - Student Registration

PLAIN LOCAL SCHOOL DISTRICT - STUDENT REGISTRATION

Revised: 2/5/2013 dlb

SECTION I: STUDENT INFORMATION

Enrolling in [school]:______Today’s Date ______Grade ______

Previously attended Plain Local Schools? _____Yes_____NoWhat grades? ______

Full Legal Name ______/______/______

LastFirstMiddle

Preferred Name ______Social Security Number ______(optional)

Birthdate _____/______/______Gender MFMother’s Maiden Name ______

Month Day Year

Is student of Hispanic/Latino origin?** _____Yes_____No **(Cuban, Mexican, Puerto Rican, South/ Central

American, other Spanish culture or origin, any race)

Racial Group (Choose one or more) [Note: If no selection is made, school personnel are required to make a observer identification.]

______African American _____ American Indian_____ Asian _____Caucasian

______Multiracial _____ Pacific Islander or Alaskan_____ Other (Specify) ______

City of Birth ______Country of Birth* ______

What Language(s) does your child speak? * ______

Years of Preschool: (circle one) 0 1 2 3 Name of Preschool: ______

Has student been identified as Gifted? _____ Yes ____ No In what area(s)? ______

Does student receive any of the following services:

Special Education (IEP)? _____Yes_____NoEducational services via a 504 plan? _____Yes_____No

Gifted Intervention Services? _____ Yes* ____ No *In what subjects/areas? ______

SECTION II:RESIDENCY

Street Address ______Apt No: ______

City______ZIP______Phone Number______(landline, or cell if none)

Proof of Residency: _____ utility bill _____ phone bill _____ rental/purchase agreement_____ other ______

SECTION III:PARENT/GUARDIAN/CUSTODY INFORMATION

Student lives with:_____ Both natural parents - skip to Section V

_____ Natural mother only_____ Natural Mother & Step Father

_____ Natural father only_____ Natural Father & Step Mother

_____ Legal Guardian - see Section IV_____ Court/Foster Placement - see Section IV

_____ Full Custody. Which parent?______

_____ Joint Custody. Residential parent:______

_____ Shared Parenting Plan - School district of non-residential parent:______

Name of non-custodial parent:______Home Phone:______

Address of non-custodial parent:______

Is non-custodial parent to receive report cards and other school related mailings?_____ yes_____ no

Does the non-residential parent have visitation rights?_____ yes_____ no
SECTION IV:ENROLLMENT VERIFICATION - if home address is in the Plain Local District, please skip this section.

In what district do you reside? ______

Type of non-resident enrollment:

_____ Tuition_____ Superintendent’s Agreement [must be signed by both school districts]

_____ Foster [Copy of judgment entry required]Responsible District:______

Natural Mother:______Current Address:______

Natural Father:______Current Address:______

_____ Grandparent EnrollingName:______

Type of Grandparent Enrollment: _____District approved grandparent waiver _____Court Appointed

_____ Power of Attorney OR _____ Caretaker Affidavit [student is enrolled as resident student for both]

SECTION V:CONTACT INFORMATION

Contact #1

First Name:______Last Name:______

Relationship:______Address same as student? Yes No

Address:______City, State, Zip:______

Home Phone: ______Mobile Phone:______

Pager:______Email: ______

Occupation:______Place of Employment:______

Business Phone: ______Authorized to pick up child ______Yes ______No

_____Legal Guardian_____Migrant Work_____Non-residential parent requests mailings

_____Medical Contact_____Emergency Contact _____Willing to Volunteer

_____Available at Work_____Living with Student

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Contact #2

First Name:______Last Name:______

Relationship:______Address same as student? Yes No

Address:______City, State, Zip:______

Home Phone: ______Mobile Phone:______

Pager:______Email: ______

Occupation:______Place of Employment:______

Business Phone: ______Authorized to pick up child ______Yes ______No

_____Legal Guardian_____Migrant Work_____Non-residential parent requests mailings

_____Medical Contact_____Emergency Contact _____Willing to Volunteer

_____Available at Work_____Living with Student

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Contact #3

First Name:______Last Name:______

Relationship:______Address same as student? Yes No

Address:______City, State, Zip:______

Home Phone: ______Mobile Phone:______

Pager:______Email: ______

Occupation:______Place of Employment:______

Business Phone: ______Authorized to pick up child ______Yes ______No

_____Legal Guardian_____Migrant Work_____Non-residential parent requests mailings

_____Medical Contact_____Emergency Contact _____Willing to Volunteer

_____Available at Work_____Living with Student