Valdosta City Schools

Student Registration

For Office Use:

Grade/Teacher _____/______GTID#

Infinite Campus ID #assigned______

Student Name:______

Last Name First Name Middle Name (suffix: Jr., III)

Birthday:______Birth Place:______U. S. Citizen? Yes No

Month/Day/Year City State (Circle One)

Student Address:______

Street City State Zip

Student Email Address:______Not Applicable

Primary Contact Phone:______

(This number will be used for automated calls/messages)

County of Residence:______Birth Country:______

Start Date in US Schools:______Sex: M F Ethnicity(Complete Part A and B): Month/Day/Year

(Circle One) Part A: Is the student Hispanic/Latino? (choose only one)

_____ No, not Hispanic/Latino

_____ Yes, Hispanic/Latino (a person of Cuban, Mexican, Puerto Rican, Cuban, South

or Central American, or other Spanish Culture or origin.)

Part B: What is the student’s race? (choose one or more)

_____ American Indian or Alaska Native

_____ Asian

_____ Black or African American

_____ Native Hawaiian or Other Pacific Islander

_____ White

Student resides with: Both ParentsMotherFatherFoster ParentLegal Guardian

Parent/Guardian1:______

Last Name First Name Middle Name ( suffix: Jr., III)

Relationship to Child:______Cell Phone:______

Address:______Home Phone:______

(If different from Student Address)

Email Address:______

Employer:______Work Phone:______

Parent/Guardian2:______

Last Name First Name Middle Name ( suffix: Jr., III)

Relationship to Child:______Cell Phone:______

Address:______Home Phone:______

(If different from Student Address)

Email Address:______

Employer:______Work Phone:______

Parent/Guardian is Active Duty in US Armed Forces? Yes  No

Parent/Guardian is employed on a military base? Yes  No

VCS Registration 3-27-14 (OVER) Page 1 of 2

School Last Attended:______

Name of School

______

City State Phone Number

Has your child ever been enrolled in Valdosta City Schools:  Yes  No

If yes, list name of school:______

List Preschool/Pre-K your child attended:______

Has your child received any of the following special services in previous school or VCS? Check all that apply.

Special Education Speech Gifted  ESOLMigrantSST/504Remedial

List any allergies or current medication:______

List other siblings attending VCS that reside with this student:______

______

Emergency Contacts:

______

Name & Relationship to Student Phone

______

Name & Relationship to Student Phone

How will your child get home?  Bus Car  Walk  Day Care Van Other:______

Authorization to Enroll and Withdraw Your Student

For school purposes,______and/or ______

Parent/Guardian 1 Parent/Guardian 2

shall be designated as the enrolling parent(s)/guardian(s). I/We understand once an enrolling person(s) is designated, school officials are required by law to honor said designation until the same is changed by the undersigned in writing, or a Court Order is entered meeting the requirements of OCGA§20-2-780. Once an enrolling person(s) is designated, this designation is not affected by a change on the emergency contact card.

______

Parent/Guardian Signature Date

Affidavit of Residence

I/We, ______certify, swear and/or affirm as follows that:

Parent/Guardian Signatures

  1. I am the parent/court appointed guardian of the child listed above.
  2. The child listed above resides with me full time at the address listed above.
  3. I understand that I must immediately notify Valdosta City Schools if I change residence or if the child listed above should change residence.
  4. The above information is to the best of my knowledge and belief, true, correct, and complete.
  5. I understand that representatives of Valdosta City Schools may visit my home to verify residency, and I hereby voluntarily consent to such visits.
  6. Representatives of Valdosta City Schools may verify residency through property management, homeowners, landlords, and/or utilities, and I hereby voluntarily consent to such verification.
  7. I understand that a student enrolled in Valdosta City Schools under falsified information is illegally enrolled and will be immediately withdrawn from school.
  8. I understand that false swearing is in violation of the laws of the State of Georgia and is punishable by a fine of not more than $1,000 or by imprisonment for not less than one of more than five years, or both. OCGA§16-10-71.

VCS Registration 3-27-14 Page 2 of 2