Colquitt County Schools Enrollment Packet. Request Forms Middle School

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1 Enrollment Packet Request Forms Middle School

2 Statement of Objection to Use of Social Security Number for Student Identification Request I do not wish to provide the Social Security Number of my child/children. No deseo otorgar el número de seguro social de mi hijo/a. Name of School System/Nombre del sistema escolar Name of First Child/Nombre del primer hijo Name of Second Child (If appropriate)/nombre del segundo hijo (si es apropiado) Name of Third Child (If appropriate)/nombre del tercer hijo (si es apropiado) Name of Fourth Child (If appropriate)/nombre del cuarto hijo (si es apropiado) Name of Fifth Child (If appropriate)/nombre del quinto hijo (si es apropiado) Signature of Parent/Guardian / Firma del padre/ tutor Date / Fecha Signature of Notary Public / Firma del Notario Publico Date of Expiration of Notary Public / Fecha de expiración del Notario Publico 1rssnoptout.doc

3 COLQUITT COUNTY BOARD OF EDUCATION Dr. Samuel A. DePaul, Superintendent Affidavit for Establishing Residency Student s Name: Date of Birth: I declare under penalty of perjury under the laws of Georgia that the foregoing is true and correct and of my own personal knowledge, and that, if called upon to testify, I would be competent to testify thereto. I,, am the parent/guardian of. (Print Parent/Guardian Name) (Student s Legal Name) My child and I currently reside at: Address: City: State: Zip Code: Phone Number: Currently, I do not have any documentation to link me to the above physical address because I do not receive any bills in my own name. The person with whom I currently reside/person who owns the property in which I reside is: Person s Name: Phone Number: Address (If different from your residence): Proof of residency for the person with whom you live/property owner must be attached to this affidavit. Acceptable residency documents include: Current lease, property tax notice, homeowner s insurance bill, mortgage statement, current vehicle registration form, any utility bill listing the residence as the service address. A cell phone bill or a driver s license is NOT an acceptable proof of residency. Signature of Parent/Guardian: Signature of Person with Whom You Reside/Property Owner: School Official or *Notary Signature: Date: (*This affidavit must be notarized if it is not signed in the presence of a school official.) FOR SCHOOL USE ONLY: Received by: Date Received: Proof of Residence Attached

4 REQUEST FOR ADMINISTRATION OF MEDICATION Request If this form is properly completed and returned to the school nurse, the Colquitt County School System may assist parents when their child s physician has prescribed medication for the child. The medication will only be given if it is delivered to the nurse or his/her designee in the original bottle marked with the student s name, dosage, time of administration, physician, pharmacy, and the date of expiration. Student s Name DOB School Grade Teacher STATEMENT OF PHYSICIAN Medication Date of Prescription Number or amount of medication received: Dosage to be given Time(s) to be given at school: Discontinue medication on Allergies: Diagnosis: Possible medication side effects: Action to be taken by school if any side effects: Other medication the student is taking: Other instructions: Physicians Signature: Physician s Address/Phone: Statement of Parent/Guardian As the parent/guardian of the above named student, I do hereby request the school system give medication to the above named student at the times listed below. I understand that the school system is not legally obliged to administer medication to the student. School personnel will administer the medication. I agree not to institute suite against the school system for the administration or non-administration of the medication, to defend and hold the school system harmless from any liability resulting from the administration or non-administration of the medication, and to defend and indemnify the school system and its employees from any liability arising out of this agreement. I understand that it is my responsibility to notify the school nurse or designated health personnel immediately concerning any medication changes. As the parent/guardian I also authorize the prescribing physician named above to discuss with the principal or his/her designated staff member any matter regarding the medication to be administered or treatment to be performed. Time(s) to be given at school: Signature of Parent/Guardian Date: Home Phone: Work Phone: 3rRequestforMedication.doc

5 REQUEST FOR ADMINISTRATION OF MEDICATION Request If this form is properly completed and returned to the school nurse, the Colquitt County School System may assist parents when their child s physician has prescribed medication for the child. The medication will only be given if it is delivered to the nurse or his/her designee in the original bottle marked with the student s name, dosage, time of administration, physician, pharmacy, and the date of expiration. Student s Name DOB School Grade Teacher STATEMENT OF PHYSICIAN Medication Date of Prescription Number or amount of medication received: Dosage to be given Time(s) to be given at school: Discontinue medication on Allergies: Diagnosis: Illness Requiring Medication: Possible medication side effects: Action to be taken by school if any side effects: Other medication the student is taking: Other instructions: Physicians Signature: Physician s Address/Phone: La Declaración de Parent/Guardian Como el parent/guardian del estudiante nombrado anterior, yo pido el sistema escolar por la presente de la medicación al estudiante nombrado anterior. Yo entiendo que el sistema escolar no se obliga a administrar la medicación al estudiante legalmente. El personal de la secuela administrara la medicación. Yo estoy de acuerdo no instituir el traje contra el sistema escolar para administración o noadministration de la medicación, defender y sostener el sistema escolar indemne de cualquier obligación que es el resultado de la administración o nonadminitration de la medicación, y defender e indemnizar al sistema escolar y sus empleados de cualquier obligación que se levanta fuera de esta acuerdo. Yo notificare al principal escolar inmediatamente si la medicación se cambia La firma de Parent/Guardian La Fecha: El Telefono de la casa: El teléfono del trabajo : 3rRequestforMedicationspan.doc

6 Willie J. Williams Middle School Middle School Withdrawal Form ST SW (FAX) Moultrie, GA Name: SS# GTID# Grade Teacher Name: Date Enrolled: Date Withdrew: # of Days On Roll: Days Present: Days Absent: Birthdate: Transferring to: Parents/Guardian Name: Course Grade Book Returned Yes No Cost Reading Teacher Signature Math Language Arts Social Studies Science Connections Connections Media Center Book Returned Yes No Cost Signature Book Title Cafeteria Money Signature Owed: Counselor Career Interest # Completed: Signature Inventories Yes No Special Ed Services Grade Appropriate S L O Pre Test Post Test Discipline Records Course: ESOL Course: Gifted Course: Parent Signature: Registrar s Signature: 4rwithdrawalformms.doc

7 Parent Portal Registration Form In order to protect the confidentiality of the student records, all parent/legal guardians who want to use this service are required to fill out this form and return it in person to any one of your students' schools. Parents and guardians must provide a Photo ID with when returning the form. Household Information Please provide the parent or legal guardian information for your household. Parent/ Guardian Last Name Parent/ Guardian First Name Physical Address City, State Mailing Address Zip Code Home Phone Work Phone Cell Phone address (required) Student Information (Please list only students currently enrolled in the Colquitt County School system for which you are the father, mother, or legal guardian.) Student Last Name Student First Name Student Middle Name School Your Relationship to student (mother, stepparent, etc.) Resides in same household (Yes or No) Grade Level By my signature below, I affirm that all of the above information is true and that I have legal authority to access the records of the student(s) listed above. Signed: Signature & Photo ID must be that of the Parent/Legal Guardian shown on the first line Date: (mm/dd/yyyy) Important Once the above information is verified and processed, you will receive your Infinite Campus Activation Key along with directions on how to access the site and create your User Name and Password. This information will be sent through the listed above. Office Use Only Form & ID Date Returned: ID Verified Checked By: Verify Activation Key Provided Date Key Provided: Initials: Parent Portal Request Form July 2010

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