WAYNE LOCAL SCHOOL DISTRICT 659 Dayton Road, Waynesville OH 45068

Transcription

1 WAYNE LOCAL SCHOOL DISTRICT 659 Dayton Road, Waynesville OH Waynesville Elementary School Waynesville Middle School Waynesville High School Grades K 5 Grades 6 8 Grades 9 12 Phone (513) Phone (513) Phone (513) Fax (513) Fax (513) Fax (513) ENROLLMENT CHECKLIST ALL OF THE FOLLOWING MUST BE PRESENTED/COMPLETED AT THE TIME OF ENROLLMENT Child s Name: DOB: Enrollment Forms Student Registration Form (included in enrollment packet, 2 pages) Request for Transfer of School Records Form (included in enrollment packet) Driver s license or state issued photo identification of individual enrolling student Original birth certificate or passport copies will not be accepted nor hospital birth record. Immunization Records Student s Social Security Card Transcript/Last report card from prior school (if applicable) Health History Questionnaire (included in enrollment packet) Proof of Residency* Submit One of the Following: Current signed lease or rental agreement showing parent/guardian s name and address along with the landlord s name, address and telephone number Warranty deed Settlement statement Mortgage statement Property tax statement District Residency Confirmation Form AFFIDAVIT I (included in enrollment packet) Must be completed, notarized and returned at registration by parent/guardian if they own/lease property in Wayne Local School District. AFFIDAVIT II (included in enrollment packet) ONLY needs completed if the parent/guardian does not own property in the Wayne Local School district but resides with someone who does. This person must complete this form and sign in the presence of a Notary. Custody/Guardianship/Adoption Papers (if applicable) If a child lives in the Wayne Local School District with the divorced parent who has legal custody, the parent must provide a copy of the court ordered custody agreement to the school which indicates that the parent is the residential custodian of the child for school purposes. Guardianship or legal custodial documents must contain an Assignment of Tuition. Adoptions must provide an official court document and the newly issued birth certificate. IEP/504 PLAN/ETR (if applicable for students with Special Needs) Copy of most recent Individualized Education Program (IEP) if possible. Process of Building, or Purchase Contract (if applicable) If parent/guardian is in the process of building or purchasing a home in our district, and is not physically residing at the address until after the registration process; a signed contractor s agreement or purchase contract is still required and must show the approximate move in date. The Application for Student(s) to enter Wayne Local Schools prior to Residence must be completed prior to registration. This form is available in the Elementary office.

2 Student Registration Form Are you a resident of Wayne Local School District? Yes No Has your child ever been enrolled in Wayne Local School District? Yes No Enrollment Date OFFICE USE: PLEASE PRINT Student Legal First Name Legal Middle Name Legal Last Name called Name Mother's Maiden Name Student's Social Security # - - Student's Date of Birth Gender M/F Birthplace City State Native Language Grade _ Street Address PO Box # _. Apt. # Lot # City _ State Zip Home Phone (_) School Previously Attended City Stale _ CITIZEN STATUS OF STUDENT: U.S. Citizen Non-U.S. Citizen/Immigrant RACIAL/ETHNIC GROUP: Is the student of Hispanic/Latino heritage? Yes No What race is the student? (Choose ONE OR MORE) White (Persons having origins in any of the original peoples of Europe, North Africa or the Middle East) Black or African American (Persons having origins in any of the Black racial groups of Africa) Asian (Persons having origins in any of original peoples of the Far East, Southeast Asia, or the Indian subcontinent. American Indian or Alaskan Native (People who maintain tribal affiliations or community attachment to the original peoples of North, South and Central America) Native Hawaiian or Other Pacific Islander (Persons having origins in any of the original people of Hawaii, Guam, Samoa, or other Pacific Islands) The U.S. Department of Education allows observer identification if a parent or guardian refuses to provide their child s racial/ethnic group. The observed designation will be communicated to the parent or guardian by the district prior to designation. HOME LANGUAGE SURVEY State and Federal regulations requires Wayne-local Schools to have the following Home Language Survey completed and on file for every child enrolled in our district. Please answer all questions. Please Print. For Parents/Guardians: Please answer the following questions: 1. What language did your son/daughter speak when he/she first learned to talk? 2. What language does your son/daughter use most frequently at home? 3. What language do you speak most frequently to your son/daughter? 4. What language do the adults at home most often speak? 5. How long has your son/daughter attended school in the United States? I understand that State and Federal regulations require the school district to collect information regarding my child's native language. The above information is true and accurate. Parent/Guardian Signature X Date Is this child receiving Special Education Services? Yes No If yes, does this student have a current IEP? Yes No Is this child receiving Gift Education Services? Yes No If yes, does this student have a current WEP Yes No Page 1of 2 Revised 02/2016

3 STUDENT NAME: GRADE: Student lives with: Two parents present (natural or step) Living with Mother and Father Living with Mother and Stepfather Living with Father and Stepmother Living with Legal Guardian One parent present (natural or step) Living with Mother Living with Father Living with Foster Parents Other siblings in the Wayne local School District: Name Grade Name Grade Name Grade Name Grade Status of Parents: Married Divorced Widowed Separated Single/Never Married Iif divorced, who has legal custody? Mother Father Shared Parenting Custody Papers? Yes No Are you the natural/adoptive parent(s) of the child? Yes No Was the child court placed in your home? Yes No If yes, Date of Assignment County _ If foster/guardian, in which district did the natural parent(s) reside at the time of placement FATHER/GUARDIAN: MOTHER/GUARDIAN: Name Name Address (if different) Address (if different) Home/cell phone Home/cell phone Employer Employer Work Phone Work Phone Stepmother (if applicable) Stepfather (if applicable) Cell work phone Cell work phone Falsification under Ohio Revised Code section is a misdemeanor of the first degree punishable by a maximum of six months imprisonment or a fine of $1,000 or both. I, the undersigned, do hereby state and declare under penalty of falsification that I am the parent or legal guardian of the student named on this form and that this registration information is true and correct. Parent/Guardian Signature Date: Page 2 of 2

4 Wayne Local School District #IRN Dayton Road, Waynesville, Ohio REQUEST FOR RELEASE OR TRANSFER OF SCHOOL RECORDS Name of Student Date of Birth Grade School Year Last school Attended Address of last school attended Phone Number Fax Please release records to: Waynesville High School Waynesville Middle School Waynesville Elementary School FAX (513) FAX (513) FAX (513) Date Signature (Must be the Parent, Legal Guardian or Self (if over 18) PLEASE INCLUDE THE FOLLOWING: 1) School records including Transcripts Current grades State test scores and other standardized test scores 2) Health Records All shot records Vision and hearing screenings 3) Any Psychological records (most recent) IEP/ETR WEP-Gifted 504 Plan TO BE COMPLETED BY PREVIOUS SCHOOL DISTRICT: The student listed above is: NOT EXPELLED/RECOMMENDED FOR EXPULSION from another school district at this time. EXPELLED/RECOMMENDED FOR EXPULSION from the school district at this time. The period of expulsion expires on. School Official s Signature Date: Student SSID # DISTRICT IRN#

5 WAYNE LOCAL SCHOOL DISTRICT 659 Dayton Road, Waynesville, OH AFFIDAVIT I State of Ohio, Warren County I, being duly cautioned, so solemnly swear or affirm the following: 1. I am the parent, guardian or legal custodian of and I live at. 2. This has been my place of residence since. My address immediately prior to this date was. 3. I acknowledge and understand that if the above information is not true and correct, that knowingly swearing or affirming the truth thereof constitutes criminal falsification, a violation of Ohio Revised Code Section , a first degree misdemeanor, punishable by a maximum fine of $1,000 and/or a maximum term of imprisonment of six months. Further, if the student is found not to be a legal resident, the district will seek remuneration for each day the student illegally attended school in the district. I agree that Wayne Local School District, if they deem necessary, have the right to investigate my residency. I agree to allow the release of rental information and also utility customer information to a representative of the Wayne Local School District. TRUE FALSE 4. The above address is where I eat and sleep overnight the majority of the time. 5. The above address is where my child(ren) eat and sleep majority of the time. 6. I do not own, rent, or lease a house/apartment outside of Wayne Local School District. 7. I am not provided with living space outside the Wayne Local School District by a friend, relative or government agency. 8. Voter registration (if applicable) will use the above residence in determining precinct. If you marked FALSE on any of the above statements, please explain: ****MUST BE SIGNED IN THE PRESENCE OF A NOTARY**** Parent/Guardian Signature Date: Sworn to or affirmed and subscribed before me this day of, By Notary Public

6 WAYNE LOCAL SCHOOL DISTRICT 659 Dayton Road, Waynesville, OH ****Complete this Affidavit only if you DO NOT own or rent property in the Wayne Local School District but reside with someone who does. The person you reside with must complete this form and provide proof of residency (rental/lease agreement, copy of deed, settlement statement, Warren County Auditor Statement/tax bill). AFFIDAVIT II State of Ohio, Warren County I, being duly cautioned, so solemnly swear or affirm the following: 1. I am the owner/renter of the residence at located in the Wayne Local School District. 2. The following individuals(s) is/are living at my abovestated residence and have since the day of,. 3. I acknowledge and understand that if the above information is not true and correct, that knowingly swearing or affirming the truth thereof constitutes criminal falsification, a violation of Ohio Revised Code Section , a first degree misdemeanor, punishable by a maximum fine of $1,000 and/or a maximum term of imprisonment of six months. Further, if the student is found not to be a legal resident, the district will seek remuneration for each day the student illegally attended school in the district. I agree that Wayne Local School District, if they deem necessary, have the right to investigate my residency. I agree to allow the release of rental information and also utility customer information to a representative of the Wayne Local School District. ****MUST BE SIGNED IN THE PRESENCE OF A NOTARY**** Signature Date: Sworn to or affirmed and subscribed before me this day of, By Notary Public

7 Ohio Department of Health School and Adolescent Health Health History Student s name Sex Male Female Date of birth / / Family Health History Please list allergies, heart problems, diabetes, cancer or other serious health conditions. Father Mother Brothers and Sisters Birth and Developmental History No unusual birth or developmental history Did the mother have any unusual physical or emotional illness during this pregnancy? Yes No Was infant born full term? Yes No Did the infant have any sickness or problems? Yes No Briefly explain illness or problems. How does the child s development compare to other children, such as his or her brothers/sisters or playmates? About the same Delayed Advanced Student Health Conditions, my child received regular medical/health care for the following conditions: medical conditions Allergies Diabetes Seizure disorder Asthma Depression Sickle cell anemia ADD/ADHD Ear problem/hearing difficulty Skin conditions Autism Emotional concerns Speech problems Behavior concerns Headaches Traumatic brain injury Birth/congenital malformations Heart problems Vision problems (glasses, contacts) Bone/muscle/joint problems Hemophilia Other Blood problems Juvenile arthritis Other Bowel/bladder problems Lead poisoning Other Cancer Migraines Other Cystic fibrosis Neuromuscular disorder Other Please explain any conditions above or any reason for hospitalizations. Please indicate any allergies your child may have. Allergy type Reaction School restrictions or recommended actions Bee/Insect Food Medication Other

8 Health History continued Please list any prescription and over the counter medication that your child takes on a regular basis. Medication and dose Time Reason Do any health and/or medical conditions require school restrictions, modifications, and/or intervention? Yes No If YES, please explain. Does the student require any special procedures and/or treatments for their health condition(s)? Yes No If YES, please explain. Please indicate any other information about your child s health or development that you think would be helpful for the school to know. Form completed by Relationship to student Date / /