YORK SUBURBAN SCHOOL DISTRICT – REGISTRATION FORM
January 15, 2018 | Author: Anonymous | Category: N/A
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YORK SUBURBAN SCHOOL DISTRICT – REGISTRATION FORM DATE:_____________
STUDENT INFORMATION LAST NAME:______________________________ FIRST:___________________________ MIDDLE:_____________________ SUFFIX________ NICKNAME:__________________
BIRTH DATE:_____/______/______
GENDER: MALE
FEMALE
GRADE:_______
ETHNICITY (CIRCLE ONE): WHITE BLACK (NON HISPANIC) HISPANIC AMERICAN INDIAN ASIAN/PACIFIC ISLANDER ALASKAN
HOUSEHOLD ADDRESS (PRIMARY): ______________________________________________________________________APT #: ________ CITY:_________________ STATE: PA ZIP:__________ PRIMARY PHONE: (
STUDENT ENTRY DATE INTO USA:_______________
)______________________UNLISTED:
YES
NO
STATE START DATE:_____________
STUDENT ENTRY DATE INTO USA SCHOOL______________
LANGUAGE SPOKEN AT HOME _________________
PRIMARY HOUSHOLD MEMBERS(LIST EVERYONE LIVING IN THE HOME WITH THE STUDENT) LAST NAME FIRST NAME BIRTHDATE RELATION TO STUDENT /
/
/
/
/
/
/
/
/
/
PARENTS/GUARDIANS NOT LIVING IN PRIMARY HOUSEHOLD (SECONDARY) LAST NAME FIRST NAME RELATION TO STUDENT
RECEIVE MAILINGS YES
NO
YES
NO
SECONDARY ADDRESS: ______________________________________________________________________APT #: _____________ CITY:___________________________ STATE: ___________ ZIP:________________ PHONE: (
)
UNLISTED:
YES
JOINT CUSTODY:
YES
NO
NO
CONTACT INFORMATION DURING SCHOOL HOURS – 7:30AM TO 4:30PM FATHER/GUARDIAN’S DAYTIME/WORK PHONE : (______)______________________EXT:________ CELL: (_______)____________________ EMAIL:___________________________________________________ MOTHER/GUARDIAN’S DAYTIME/WORK PHONE : (______)_______________________EXT:________ CELL: (______)____________________ EMAIL:___________________________________________________ PREVIOUS SCHOOL INFORMATION NAME OF SCHOOL DISTRICT :_______________________________________________________PHONE:(_____)______________________ BUILDING OF ATTENDANCE:____________________________________ SCHOOL ADDRESS:______________________________________CITY: _______________________ STATE:____________ZIP: ______________ SCHOOL OFFICIAL/COUNSELOR:______________________________________ FAX: (_____)_________________________________________ WITH THE FOLLOWING PARENT/GUARDIAN SIGNATURE, I STATE THE ABOVE INFORMATION TO BE TRUE
__________________________________________________________ (Parent/Guardian Signature) Form #1R 1/26/09
YORK SUBURBAN SCHOOL DISTRICT – REGISTRATION FORM
Pg. 2 OFFICE USE ONLY: BUILDING OF ATTENDANCE: _____________________________________ STUDENT NO:______________________ STUDENT NAME:______________________________________________ ENTRY CODE: E____ or R______
ENTRY DATE: ______________________ GRADE: ___________
H.R. TEACHER:______________________________________ ROOM #:_____________ DISABILITY/EXCEPTIONALITY CODE: ________ GUIDANCE COUNSELOR: ______________________ COUNSELOR # :______ DISTRICT START DATE:____________ SCHOOL START DATE:____________ PA SECURE ID#:_________________________________________
TRANSPORTATION: BUS STOP NAME: ____________________________________________________ BUS #:________ RESIDENCY: NON-RES: ___________ TUITION:___________ FOSTER:_________ PLACEMENT PAPERS: _________________
Form #1R 1/26/09
YORK SUBURBAN SCHOOL DISTRICT – EMERGENCY INFORMATION FORM DATE:_____________
STUDENT INFORMATION LAST NAME:_____________________________ FIRST:__________________________ MIDDLE:__________________SUFFIX:________ NICKNAME:______________ GENDER: MALE
FEMALE
BIRTH DATE:_______/__________/_________ GRADE:__________________ STUDENT RESIDES AT: _________________________________________________________APT #:________ CITY:___________ STATE:_____ ZIP CODE: __________ HOME PHONE: (_______)______________________________ UNLISTED: YES
NO
EMERGENCY INFORMATION( NON-HOUSEHOLD CONTACTS): (PLEASE LIST SOMEONE WHO LIVES LOCALLY AND HAS RESPONSIBILITY FOR YOUR CHILD.) CONTACT NAME:_______________________________________RELATIONSHIP:_____________________________ DAYTIME PHONE:_______________________CELL PHONE:_____________________________ CONTACT NAME:_______________________________________RELATIONSHIP:_____________________________ DAYTIME PHONE:_______________________ CELL PHONE :____________________________
PHYSICIAN:___________________________________________________________PHONE:__________________________________
HOSPITAL (PLEASE CIRCLE ONE): MEMORIAL OR
YORK
PERMISSION TO TRANSPORT: YES
NO
SENSITIVITY TO DRUGS:_________________________________________________________________________________________________________ SPECIFIC HEALTH PROBLEMS:_____________________________________________________________________________________________________ WITH THE FOLLOWING PARENT/GUARDIAN SIGNATURE, I STATE THE ABOVE INFORMATION TO BE TRUE AND ALSO GIVE PERMISSION FOR EMERGENCY TREATMENT FOR MY STUDENT: ________________________________________________ (PARENT/GUARDIAN SIGNATURE)
Form #2 EC 1/26/09
YORK SUBURBAN SCHOOL DISTRICT PROOF OF RESIDENCY FOR ENROLLMENT STUDENT INFORMATION: Name of Student 1 _____________________________________ Grade ____________ [ ] Valley View [ ] East York [ ] Indian Rock [ ] Middle School [ ] High School Name of Student 2 _____________________________________ Grade ____________ [ ] Valley View [ ] East York [ ] Indian Rock [ ] Middle School [ ] High School Name of Student 3 _____________________________________ Grade ____________ [ ] Valley View [ ] East York [ ] Indian Rock [ ] Middle School [ ] High School
PARENT/GUARDIAN INFORMATION: Name of Parent(s)/Guardian: _______________________________________________ Address_________________________________________________________________ Street Address City State Zip Home Phone Number __________________ Work Phone Number _________________ Current Residence (If Different from Above): ________________________________________________________________________ Street Address City State Zip Attach one of the following to substantiate residency in the district: [ [ [ [
] ] ] ]
Utility Bill Pennsylvania Department of Transportation Identification or Drivers License Pennsylvania Department of Transportation Vehicle Registration Copy of sales agreement/contract with settlement date, lease rental agreement, rent receipt, or other similar document which verifies intent to establish residency.
Through my signature, I/we grant the school district permission to investigate the above information that I/we have presented in this residency affidavit for confirmation and factual accuracy. If investigation discloses that these statements are false or that you are not a legal resident of the York Suburban School District, you will be liable for tuition for the period of time of non-residency. Signature of Resident Parents/Guardians: ______________________________________ Date: _____________________
______________________________________
This form must be completed for all students prior to enrolling in the district. Residency exceptions (e.g. Future residents, students residing with persons other than parent or legal guardian) must be processed through the Superintendent’s Office.
YORK SUBURBAN SCHOOL DISTRICT SWORN STATEMENT LEGAL AUTHORITY – Section 1034-A Sworn Statement—(A) Prior to admission to any school entity, the parent, guardian or other person having control or charge of a student shall, upon registration, provide a sworn statement or affirmation stating whether the pupil was previously suspended or expelled from any public or private school of this Commonwealth or any other state for an act or offense involving weapons, alcohol or drugs, or for the willful infliction of injury to another person or for any act of violence committed on school property. The registration shall be maintained in the student’s disciplinary record. (B) Any willful false statement made under this section shall be a misdemeanor of third degree.
+++++++++++++++++++++ I, ___________________, do hereby swear or affirm that I am the parent, guardian, or person having control of _____________________ who is registering as a student in the York Suburban School District. I further swear or affirm that _____________________ has/has not (strike out the inappropriate has or has not) ever been suspended or expelled from any public or private school of this Commonwealth or any other state for an act or offense involving weapons, alcohol or drugs, or for the willful infliction of injury to another person or for any act of violence committed on school property. If the student has been suspended or expelled for any of these offenses, it is your obligation to provide information relative to the date, the name and location of the school, and the charges on which the suspension or expulsion was based. This information should be provided on the reverse of this form or by the way of other official documentation attached to this form.
_____________________________ Witness
___________________________________________ Signature of Parent/Guardian/Person Having Control
_____________________________ Witness
___________________________________________ Street Address ___________________________________________ City, State, Zip
OR
___________________________________________ Phone Number
Notarization: ____________________________ (SEAL)
___________________________________________ Township of Residence
York Suburban School District Home language Survey Name: ______________________________________Date:_____________ Date of Birth:_______________________Age:______Grade:____________ Parent/Guardian Name: __________________________________________ Telephone (
) _____________________
1. Is your family and child’s first language English? Check one of the following: Yes________(If yes, stop survey here) No ________(If no, please continue with survey)
2. What language does your child speak most often at home?
3. What language(s) do you use when speaking to your child?
4. What language(s) is spoken most often in your home?
5. What language(s) does your child read?________________________ 6. What language(s) does your child write? _______________________ 7. Does your child understand, but not speak a language other than English?
Signature of Parent or Guardian: (Required)
York Suburban School District Student Health History **To be Completed by Parent** Student Name: _______________________________Date of Birth ___________ Sex: M
F
Address: _____________________________________Phone ______________ Grade _____ Father: ______________________Mother: ____________________Guardian:____________________ Last School Attended ________________________ City ____________State _______ Please check the illnesses or conditions your child has had. Include dates, if known, and important details. Allergies: Food _______________________ Insect Bites _______________________ Medications _______________________ Other _______________________ Asthma _______________________ Chickenpox _______________________ Diabetes _______________________ Ear infections _______________________ Emotional problems __________________ Fainting _______________________ Hearing Problems ___________________ Is your child currently under medical treatment?
Heart Disease ______________________ Hernia ______________________ Head injury ______________________ Orthopedic problems __________________ Pneumonia ______________________ Rheumatic Fever ____________________ Scarlet Fever ________________________ Seizures ___________________________ Skin Condition _______________________ Speech defect _______________________ Urinary tract problem__________________ Vision problems______________________ Yes
No
____________________________ Comments
Please list all medications your child is currently taking. ____________________________________ Please list any operations, serious injuries, illnesses, or other existing physical conditions. ____________________________________________________________________________ Does your child have a doctor? Yes Birth Information:
No
Is your child covered by insurance? Yes
Birth Weight: __________
Breathing difficulties at birth? Yes
No
No
Were there any abnormal conditions noted at the child’s birth? __________________________ Were there any complications during the mother’s pregnancy, labor, or delivery? ____________ VERIFICATION OF YOUR CHILD’S IMMUNIZATIONS IS REQUIRED. PLEASE ATTACH A COPY OF YOUR CHILD’S CURRENT IMMUNIZATION RECORD FROM YOUR HEALTH CARE PROVIDER. THANK YOU! _____________________________________ Parent/Guardian Signature
________________ Date
YORK SUBURBAN SCHOOL DISTRICT New Student Parent Inquiry Date: _____________________
Child’s Name: __________________________________________
Date of Birth:_____________
Address: ________________________________________________________________________ Home phone: _____________
Cell phone: _________________
Child lives with: ___ Both parents ___ Mother ___Father __ Joint Custody Other:__________ Mother’s Name: ____________________________________ Place of Employment: ________________________________Position: _______________________ Father’s Name: _____________________________________ Place of Employment:________________________________ Position: _______________________
Other children in the family:
Age:
Grade:
Sex:
______________________________________
_____
_____
_____
______________________________________
_____
_____
_____
______________________________________
_____
_____
_____
Did your child attend a preschool, Head Start, or day care program?
____Yes
____ No
Program name: ______________________________________ Does your child:
___ wear corrective lenses ___ take any medications ___ have medical concerns/under doctors care ___ receive speech/language services ___ attend LIU preschool
If yes to any of the above, please describe: __________________________________________________________________________ What holidays does your family celebrate? (This is helpful for classroom planning) __________________________________________________________________________
MORE ON THE BACK!!
Please describe recent family events or changes (death, divorce/separation, new sibling, moving):
List any special fears and your child’s reaction to those fears (cries, screams, withdrawal, etc.):
Does your child enjoy books? Do you read to your child?
___ yes ___ yes
___ no ___ no
How often? ________________
What are your child’s strengths?
What are your child’s weaknesses?
What do you expect your child to acquire through the kindergarten experience?
Please mark an X on the continuum to best describe your child in the following areas: frequently
sometimes
never
Is overly active
1-------------2-------------3-------------4-------------5
Has difficulty separating from Mom/Dad
1-------------2-------------3-------------4-------------5
Becomes upset/cries when plans change
1-------------2-------------3-------------4-------------5
Is shy/timid around others
1-------------2-------------3-------------4-------------5
Has difficulty sharing/taking turns
1-------------2-------------3-------------4-------------5
Has problems getting along with other children
1-------------2-------------3-------------4-------------5
Please use this space to list any other information you would like the teacher to know.
Permission to Release Student Information PLEASE FORWARD THIS FORM OR A COPY WITH THE STUDENT RECORDS
1. Student’s Name ___________________________________________ Grade _______
Date of Birth ____________________
has enrolled in the York Suburban School District on ________________________. 2. I hereby give permission for __________________________________________________ to release the following information to (Name of Previous School) York Suburban School District for the above-named student. It is my understanding that all information will be utilized only by professional personnel to aid my child in his/her educational program. _____ Academic Records including current withdrawal grades _____ Grading system explanation _____ Attendance Records _____ Disciplinary Records _____ Immunization Records _____ Health and Dental Records _____ School Violence Report (if applicable)
_____ Psychological/Psychiatric evaluations _____ Comprehensive Evaluation Report (CER/ER) _____ Multi-Disciplinary Evaluation (MDE) _____ Individualized Educational Program (IEP) _____ NORA/NOREP _____ PSSA or State Testing results _____ PA Secure ID
___________________________________________________
_____________________
(Signature of Parent/Guardian)
(Date)
(According to the Final-Regulations-Family Rights and Privacy Act (Buckley Amendment) date June 17, 1976, it is no longer necessary to obtain written consent to release records between schools.)
The above information is to be sent to: > Guidance Office York Suburban High School 1800 Hollywood Drive York, PA 17403 Attn: Kim Knowles Phone: 717-845-5415 Fax: 717-843-2702
>
East York Elementary School 701 Erlen Drive York, PA 17402 Attn: Gayle Rudacille Phone: 717-755-1021 Fax: 717-840-4185
>
Guidance Office York Suburban Middle School 455 Sundale Drive York, PA 17402 Attn: Judy Everett Phone: 717-840-9214 Fax: 717-757-0613
>
Indian Rock Elementary School 1500 Indian Rock Dam Road York, PA 17403 Attn: Patty Shaffer Phone: 717-845-6651 Fax: 717-843-3695
___________________________________________________ (Signature of School Official)
>
Valley View Center 850 Southern Road York, PA 17403 Attn: Peggy Dunty Phone: 717-843-0305 Fax: 717-843-3298
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