WORTH COUNTY SCHOOLS Registration Form

Transcription

1 STUDENT INFORMATION: Date: Child s Name/Nombre: Last First Middle Grade: Social Security No. (optional): Sex: Male Female Race: Black White Hispanic Asian Native Hawaiian/Pacific Islander American Indian/Alaskan Native Birthdate/Fecha de nacimiento: Age: Bus #: Address of Child/Direccion actual: Mailing Address: Street/P.O. Box City Zip Code Street Address: Street City Zip Code Home telephone number: School Last attended/escuela: Name Address City State Zip Code Telephone #: Fax #: Did your child attend a Pre-K program, public or private, prior to entering Kindergarten? Yes No If yes, what program: Public Pre-Kindergarten Head Start Private Pre-Kindergarten Has this student received any of these services: Special Education Speech Gifted ESOL/EL SST 504 Which school district: School s Name: Dates attended: Are there any activities that your child may not participate in due to religious activities? School Official Use Only: Teacher/Advisor: Date Enrolled :

2 FAMILY INFORMATION: Father/Padre/Guardian: Name: Address Street/P.O. Box City State Zip Code Home/casa Phone # Cell/cellular Place of Employment Work Phone # Address: Mother/Madre/Guardian: Name Address Street/P.O. Box City State Zip Code Home/casa Phone # Cell/cellular Place of Employment Work Phone # Address: Are you in the Military and based in Albany? Yes No Person to contact if Parent/Guardian cannot be reached: Name Address Telephone cell phone Persons with permission to pick up this child: Name Address Telephone # Name Address Telephone # Person(s) who MAY NOT pick up my child: Relationship: In case of accident or serious illness, I request the school to contact me. If the school is unable to reach me, I hereby authorize the school to call the physician indicated below and to follow his/her instructions. If it is impossible to contact this physician, the school may make whatever arrangements seem necessary. Signature of Parent or Guardian Local Physician s Name Telephone Allergies Routine medications Does child have a health problem? Yes No If so, list:

3 REQUIRED INFORMATION: WORTH COUNTY SCHOOLS If student was not born in the USA, list country of birth If not the USA, answer questions 1 and What date did the student first enter any US School? 2. Has this student been attending school in the US more than three full academic years? Yes No 3. Have you ever worked or come here with the intention of working in the fields, poultry, and meat processing plant, pulpwood timber industry, fishing or any other agricultural jobs?/ Ha trabajado o ha venido con la intencion de trabajar en el campo, la pollera, procesadora de carne, sembrando y cortando arboles, pesca, o algun otro tipo de trabajo en la agricultura? Yes/Si No 4. How many families live in the house? Is this temporary? What relationship are you to the Head of Household? 5. Is language other than English used in the home? Yes No 6. Did student have a first language other than English? Yes No 7. Does the student speak a language other than English most of the time? Yes No If YES to questions 5, 6, or 7, what is the language? Registrars: If yes to Questions 2, 3, 5, 6, or 7 contact Christie Foerster at Names of Brothers and Sisters: Name/Nombre Age Birthdate Grade/Grado School/Escuela Directions to home from school/direccion actual: Parent/Legal Guardian Signature: Date: These rules state that school officials in school systems in which the student may intend to enroll may release and receive a student s records without written consent for each release.

4 Records Request: Date: Student s Name: Date of Birth: Grade: School Requesting Information Name: Worth County High School Address: 406 West King Street Sylvester, GA Telephone #: Fax #: School Releasing Information (Provided by parent) Name: Address: City State Zip Code Telephone #: Fax #: The student listed above is seeking admission to Worth County Schools. Please assist us by providing the information listed below: Standard Educational Record Section 504 Plan Immunization Certificate Eye Ear & Dental Certificate Gifted Eligibility ESOL/ELL Record Disciplinary Transcript Social Security Number Birth Certificate Ninth Grade Enrollment Date (High School Only) Withdrawal Form Attendance Record Any other information that is vital to the student s education School Official Signature: Georgia House Bill 180 provides that a student enrolling for the first time in any school in grades seven or higher must provide a copy of his or her scholastic and discipline records. Every school system in the State of Georgia must provide complete information to a requesting school within ten (10) days of receipt of such request. Georgia requires that all students entering Georgia schools for the first time, regardless of their grade level, provide a shot record showing that they are adequately immunized. Please include this shot record in your release along with all available school records including psychological, a copy of standardized test scores, social security card, certified birth certificate, screening and health information.

5 RACE/ETHNICITY SURVEY FOR THE WORTH COUNTY SCHOOL SYSTEM The US Department of Education requires the use of new ethnicity/race codes beginning in August of All parents must complete this survey for each child so we can prepare for the required reporting. Student's Full Name: Homeroom Teacher: Grade: School: Parent's Signature: 1. EVERYONE must answer the following question. Choose the correct answer. Is your ethnicity Hispanic/Latino/Spanish Origin regardless of race? YES NO 2. EVERYONE must select ONE OR MORE of the following races regardless of how you answered question one. a. White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa) b. Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam) c. Native Hawaiian or Other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands) d. Black or African American (A person having origins in any of the Black racial groups of Africa) e. American Indian or Alaskan Native (A person having origins in any of the original peoples of North and South America including Central America), who maintains a tribal affiliation or community attachment.

6 Dr. John D. Barge, State School Superintendent School District: Date Completed: Parent Occupational Survey Please complete this form to determine if your child(ren) qualify to receive additional services under Title I, Part C Has your family moved in order to work in another city, county, or state, in the last three (3) years? Yes No If so, what is the date your family arrived in the city/town you reside? Has anyone in your immediate family been involved in one of the following occupations, either full or part-time or temporarily during the last three (3) years? (Check all that apply) 1) Agriculture; planting/picking vegetables or fruits such as tomatoes, squash, grapes, onions, strawberries, blueberries, etc. 2) Planting, growing, or cutting trees (pulpwood)/raking pine straw 3) Processing/packing agricultural products 4) Dairy/Poultry/Livestock 5) Meatpacking/Meat processing/seafood 6) Fishing or fish farms 7) Other (Please specify occupation): Name of Student(s) Name of School Grade Names of Parent(s) or Legal Guardian(s) Current Address: City: State: Zip Code: Phone: Thank You! Please return this form to the school The answers to this survey will help determine if your child(ren) are eligible to receive supplemental services from the Title I, Part C Program. Note for the school/district: When both yes and one or more of the boxes from 1 to 7 is/are checked, please give this form to the migrant liaison or migrant contact for your school/district. Please file original in student s records. Non-funded (consortium) systems should fax occupational parent surveys to the regional MEP office serving their district. For additional questions regarding this form, please call the MEP office serving your district: GaDOE Region 1 MEP, P.0. Box 780, 201 West Lee Street Brooklet, GA Toll Free (800) Fax (912) GaDOE Region 2 MEP, 221 N. Robinson Street, Lenox, GA Toll Free (866) Fax (229) GaDOE Region 3 MEP, 1414 Twin Towers West, 205 Jesse Hill Jr. Drive SE, Atlanta, GA Toll Free (800) Fax (770) Making Education Work for All Georgians 1854 Twin Towers East 205 Jesse Hill Jr. Drive Atlanta, GA An Equal Opportunity Employer

7 Dr. John D. Barge, State School Superintendent School District: Date Completed: Encuesta Ocupacional para Padres Por favor llene este formulario para determinar si sus hijos califican para recibir servicios a través del Programa de Titulo I, Parte C Ustedes se han movido para trabajar en otra ciudad, condado, o estado, en los últimos tres (3) años? Sí No Si su respuesta es Sí, en qué fecha llegaron a la ciudad/pueblo donde viven actualmente? Alguien de su familia trabaja, ha trabajado, o tiene la intención de trabajar, en una de las siguientes actividades en forma permanente o temporal o ha hecho este tipo de trabajo en los últimos tres años? (Marque todos los que apliquen) 1) Agricultura; plantando/cosechando vegetales o frutas como tomates, calabazas, uvas, cebollas, fresas, arándanos, etc. 2) Plantando o cortando árboles/juntando agujas de pino (pine straw) 3) Procesando /empacando productos agrícolas 4) Lechería o ganadería 5) Empacadoras o procesadoras de carne/pollo o mariscos 6) Pescando o criando pescado 7) Otra actividad. Por Favor especifique en cuál: Nombre de los Estudiantes Nombre de la Escuela Grado Nombre de los padres o guardianes legales: Dirección donde vive: Ciudad: Estado: Código Postal: Teléfono: Muchas Gracias! Por favor regrese este formulario a la escuela Las respuestas a este formulario van a ayudar a determinar si sus hijos califican para recibir servicios a través del programa de Titulo I, Parte C. Note for the school/district: When both (Yes) Si and one or more of the boxes from 1 to 7 is/are checked, please give this form to the migrant liaison or migrant contact for your school/district. Please file original in student s records. Non-funded (consortium) systems should fax occupational parent surveys to the regional MEP office serving their district. For additional questions regarding this form, please call the MEP office serving your district: GaDOE Region 1 MEP, P.0. Box 780, 201 West Lee Street Brooklet, GA Toll Free (800) Fax (912) GaDOE Region 2 MEP, 221 N. Robinson Street, Lenox, GA Toll Free (866) Fax (229) GaDOE Region 3 MEP, 1414 Twin Towers West, 205 Jesse Hill Jr. Drive SE, Atlanta, GA Toll Free (800) Fax (770) Making Education Work for All Georgians 1854 Twin Towers East 205 Jesse Hill Jr. Drive Atlanta, GA An Equal Opportunity Employer