Berea City School District

Checklist for Registration Student Registration is by appointment only. Please call 216-898-8300 ext. 6233 to schedule an appointment. The Berea Board of Education is located at 390 Fair Street, Berea, OH 44017. Only legal residents who are the parent or legal guardian of the child may complete the registration process. The following items are required for each student you are enrolling: Birth Certificate Original Certified Copy Passport (may require add l custody documents) Baptismal Record Custody Papers (originals with court stamp and Judge s signature are required at registration) Guardianship Custody Divorce Decree/Shared Parenting Agreement (if appropriate) Journal Entry Grandparent Power of Attorney Caretaker Affidavit Medical Information Immunization Records within 14 days of start date Parent/Guardian Identification Ohio Drivers License or State ID Social Worker ID School Records if available Withdrawal Slip State Testing Information Last Report Card/Grades in Progress IEP/ETR/MFE (if applicable) Transcripts (high school only) 504 Plan Home Schooling Documentation Other: Proofs of Residency Home Owners Mortgage Information (required if applicable) Valid Signed Lease or Owner s affidavit (required if applicable) Bank Statement Pay Stub Rental Permit/Occupancy Permit Municipal Income Tax Return Voter Registration Card Utility Bills (gas, electric, phone, cell phone) Residency/custody affidavit-always NOTE: An appointment is required for registration. Two (2) of the forms must be signed in the presence of a Notary Public before they are submitted to the Registrar. The forms are the OWNER AFFIDAVIT and the RESIDENCY AND CUSTODY AFFIDAVIT. Effective March 1, 2010

390 Fair Street Berea, OH 44017 Phone: 216-898-8300 Fax: 216-898-8551 STUDENT REGISTRATION FORM Student Name Last Name First Name Middle Name Entry Grade Social Security # (optional) Student Home - - Birth Date Month Day Year / / Number Street City Zip Code Up Down Apt. # Parent/Guardian Name Phone Number Previous school attended Kindergarten include preschool if attended Include homeschooling Name of School School District City State Is this student Hispanic/Latino? No, not Hispanic/Latino Yes, Hispanic/Latino Race (choose one or more) White/Non-Hispanic Black or African American/Non-Hispanic Asian Multiracial American Indian or Alaskan Native Native Hawaiian or Other Pacific Islander How Identified: Gender Male Female Citizenship Dual National Non-Resident Alien Resident Alien U.S. Citizen Other please name: Birthplace City State Country Native / Primary Language English Other please name: Student Lives With (check all that apply) Legal Custody (check all that apply) Mother Father Step-Parent Other (explain): Mother Father Foster Parent Guardian Spouse Self Guardian CCDCFS Other (explain): Court Journal Entry: ( / / ) Probate Court Juvenile Court County: Restrictions: District Bearing Cost(for Foster Children only): Does your child need Advanced/Honors/AP classes? Yes No If yes, describe services: Is your child identified as gifted? Yes No If yes, do you have a copy of the WEP/WAP? Does the child have a 504 plan? Yes No If yes, describe services: Has the child ever had an IEP? Yes No If yes, list year of most recent evaluation: If yes, do you have a copy of the IEP? Yes No If yes, indicate program: Is the child suspended? Yes No If yes, from what district? Is the child expelled? Yes No If yes, from what district? End Date: I do not consent to the release of email, home address, and home phone number for outreach purposes For Office Use Only: School Grade_ Start Date Student # _ New Re-entry Pilot Effective Date Feb. 1, 2010

PARENT(S) / GUARDIAN INFORMATION STUDENT NAME: Mother Single Married Divorced Separated Remarried Deceased Residential Non-Residential Dual Mailing: Yes No Last Name First Name Workplace Number Street City Zip Code Home Phone Work Phone Cellular Phone Father Single Married Divorced Separated Remarried Deceased Residential Non-Residential Dual Mailing: Yes No Last Name First Name Workplace Number Street City Zip Code Home Phone Work Phone Cellular Phone Legal Guardian Step Parent Foster Parent Other: Last Name First Name Number Street City Zip Code Workplace Home Phone Work Phone Cellular Phone Social Worker (If Applicable): Legal Guardian Step Parent Foster Parent Other: Last Name First Name Workplace Number Street City Zip Code Home Phone Work Phone Cellular Phone Social Worker (If Applicable): EMERGENCY CONTACT INFORMATION Name Relationship Name Relationship Telephone Telephone PLEASE LIST ALL OTHER CHILDREN UNDER THE AGE OF 22 WHO LIVE AT THE HOME ADDRESS Name Grade Date of Birth Gender Relationship To Student I hereby certify, under penalty of perjury, that all of the information that I have given is correct in all respects to the best of my knowledge. Date: Parent/Legal Guardian/Independent Student : Signature Date: Information Verified By: Pilot Effective Date Feb. 1, 2010

STUDENT ETHNICITY REPORT Dear Parent or Guardian, The federal No Child Left Behind Act (NCLB) requires schools to report the academic achievement and progress of all students. Along with test scores, we are also required as a school district to report each student s ethnicity. The State of Ohio allows schools to identify students as belonging to one of six ethnic categories. Those categories are: American Indian/Alaskan Native, Asian/Pacific Islander, Black/Non-Hispanic, Hispanic, White/Non-Hispanic, and Multiracial. To ensure our records reflect each student s ethnicity, we are asking you to complete the information below. Please note that the State of Ohio requires us to report students as Multiracial if no ethnic information is provided. STUDENT NAME ETHNIC GROUP (Please select the appropriate box below) American Indian/Alaskan Native Asian Black or African American/Non-Hispanic Hispanic/Latino White/Non-Hispanic Native Hawaiian or Other Pacific Islander Multiracial Parent/Guardian Signature Date Parent/Guardian Signature Date

For the purpose of establishing school residence and custody (To be completed by parent or legal guardian) SIGN ONLY AFTER CAREFULLY READING AND SIGNING IN THE PRESENCE OF A NOTARY. THE UNDERSIGNED, FIRST BEING DULY SWORN ACCORDING TO LAW, STATE THAT: I, _, certify that I am the custodial parent/legal guardian of (Parent s or Legal Guardian s Full Name) and that I have established residency at Date of Occupancy: RESIDENCY AND CUSTODY AFFIDAVIT (Student s Name) (Street Number, Name, Apt. #) (City) (State) (Zip Code) Phone # _Lease End Date (if applicable): I,, certify that I am a resident of the above residence located within the Berea City School District.. The registrar has explained to me that legal residency is determined by certain conditions, among them are that mail delivery, voting residence, and payroll city tax deductions are based on the Berea City School District address and also, that the residence where meals are taken, and where the resident parent sleeps must be the Berea City School District residence. (Photo identification, such as an Ohio Driver s License is required for identification) List the names of ALL people, both adults and children, who reside at the above address. Also, please indicate their school (if applicable) and status (i.e., homeowner, lessee, renter, parent, guardian, student, preschooler, grandparent, etc.) Attach a separate piece of paper, if needed. Last Name First Name School (If Applicable) Last Name First Name School (If Applicable) Last Name First Name School (If Applicable) Last Name First Name School (If Applicable) Last Name First Name School (If Applicable) Last Name First Name School (If Applicable) Please read each statement and then place your initials to the left of the statement. I/we certify that the information provided in this document and registration packet is true and no information has been withheld, concealed, or misrepresented for the purpose of circumventing the school attendance laws of the State of Ohio in order to enroll named students in the Berea City School District I/we understand that I/we are responsible for informing school officials of any change(s) in the residence of any parent, legal guardian, or other responsible adult. If I change my present address to another address that is within the Berea City School District, I will immediately file another residency and custody affidavit with the Board of Education of the Berea City School District. I further understand that if the above noted address ceases to be my legal residence and my new residence is outside the boundaries of the Berea City School District., I will withdraw my child(ren) from the district and will enroll my child(ren) in the new district of residence. I/we are also responsible for informing school officials of any changes to the legal custody or guardianship of the child(ren). I/we have provided the Berea City School District. with an official copy of any and all current court orders from the Domestic Relations, Juvenile, Probate or any other court which has exercised jurisdiction over the custody or residency of the children being enrolled as per Ohio Revised Code 3313.672. Custody Pending, I/we understand that under Ohio Law 3313.64 this will allow the Berea City School District to enroll this child for UP to sixty (60) days, tuition-free, with a copy of the legal documentation that custody proceedings have been started. After the sixty (60) days I/we agree to pay tuition to the Berea City School District if custody is not finalized or to submit finalized legal custody papers to the Berea City School District. I/we acknowledge the student who is being registered has not been expelled or excluded from any other school pursuant to O.R.C. Sections 3301.121 and 3313.662. I/we understand that if the student attends school while not being eligible to do so tuition free, the student and all responsible parties will be liable for tuition at a rate set by the Ohio Department of Education according to the Ohio Revised Code 3317.08 plus interest at a rate of 1.5% per month, administrative costs, court costs, and any attorney fees incurred in the collection of those sums and the student will immediately be withdrawn from the Berea City School District. I/we understand that the Berea City School District. may use whatever legal means it has at its disposal to verify my residency. I/we hereby waive my rights to confidentiality of information relative to my/our residence and give permission to the Berea City School District., the City tax Administrator, and the Regional Income Tax Agency (RITA) to release selected information such as name, social security number, and current and former addresses to confirm or deny my residency for the current or prior years. NOTE: Be sure you have read this statement carefully before you sign. Giving false information under oath is punishable as a criminal offense under the Ohio Revised Code 2921.13 and 2921.21, a misdemeanor of the first degree with a maximum fine of $1,000 and/or a jail term of six months. In cooperation with the City Prosecutors, each violation may be thoroughly and vigorously prosecuted. Signature(s) Parent/Legal Guardian/Custodian: Student 18 years of age or older: County of Cuyahoga ) ) SS: State of Ohio ) Before me, a Notary Public of the State of Ohio, came the above-named who said that he/she/they did understand the statements set forth above and did adopt said statements and the information, herein as his/her/their own, as true to the best of his/her knowledge of the consequences and penalties of falsification, and did affix his/her signature in my presence, This day of, 200 Notary Public Effective March 1, 2010

OWNER AFFIDAVIT O.R.C. 3313.64 I,, certify that I am the owner of the home/apartment located at,, OH () (City) (Zip Code) I further certify that the below listed tenants have established permanent residence in the aforementioned residence/apartment with me and, to the best of my knowledge, are not maintaining a separate residence elsewhere. Attach a separate piece of paper, if needed. _ (Adult and Relationship) _ (Adult and Relationship) _ (Adult and Relationship) (Child and Relationship) (Child and Relationship) (Child and Relationship) (Child and Relationship) Please read each statement and then place your initials to the left of the statement. I understand that it will be my responsibility to notify the Berea City School District Registration (216-898-8300) when the above-named family no longer resides in my home/residence. I understand that should any of the above statements be false, I am liable for any penalties including, but not limited to, the collection of any money owed for tuition purposes for which the law provides under the pertinent criminal code the tuition rate for the school year, plus interest at a rate of 1.5% per month, administrative costs, court costs, and any attorney fees incurred in the collection of those sums. I agree to, and stipulate, that the Berea City School District may use whatever legal means it has at its disposal to verify my residency, including having an attendance officer visit my home to ensure that the family named above, resides at this address. NOTE: Be sure you have read this statement carefully before you sign. Giving false information under oath is punishable as a criminal offense under the Ohio Revised Code 2921.13 and 2921.21, a misdemeanor or the first degree with a maximum fine of $1,000 and/or a jail term of six months. In cooperation with Berea, Brook Park or Middleburg Heights each violation may be thoroughly and vigorously prosecuted. Signatures: _ (Signature of Owner) (Date) _ (Printed Name of Owner) (Phone Number of Owner) State of Ohio ) County of Cuyahoga ) SS ) Before me, a Notary Public of the State of Ohio, came the above-named who said that he/she/they did understand the statements set forth above and did adopt said statements and the information, herein as his/her/their own, as true to the best of his/her knowledge of the consequences and penalties of falsification, and did affix his/her signature in my presence. This day of, 20. Notary Public Effective March 1, 2010

Home Language Survey Date:_ Federal guidelines require that this form be completed for all enrolled students. School:_Grade: Gender: Male Female Student Name: Birthdate:_ Country of Birth: Home :_ (Street) (City) (ZIP) Parent/Guardian Name: Home Phone: Cell Phone: Work Phone: Please answer the following questions: 1. What language did your child speak when first learning to talk? 2. What language does your child speak most often at home? 3. What language do you use most frequently when communicating with your child? 4. List the language(s), other than English, spoken by your child 5. List the language(s), other than English, spoken in the home. PARENT/GUARDIAN SIGNATURE: If your answer was any language other than English to questions 1-5, please answer the following questions. 6. What is the Parent/Guardian s native language? Mother Father Guardian 7. Does your child: speak English read English write English (Check all that apply.) 8. Which adults in the home speak English? Mother Father Guardian 9. Which adults in the home read English? Mother Father Guardian 10. Do you need an interpreter? Yes No If yes, do you have one available? Yes No 11. Interpreter s Name (If available): Phone #: 12. When did your child first attend school in the United States? Date: 13. Did your child receive English as a Second Language services in his/her former school? Yes No 14. List the schools your child attended in the United States School Name City/State Grade Dates Enrolled 15. List the schools your child attended in another country School Name City/Country Grade Dates Enrolled Effective Date Feb. 8, 2011

BEREA CITY SCHOOL DISTRICT CUSTODY DATA SHEET Student Name School / Grade Custodian / Guardian Name Rel ationship Non-Custodial Natural / Adoptive Parents Data Father: Phone: when custody was changed: Mother: Phone: when custody was changed: Should copies of all school records, meetings, etc. be mailed to the above address? yes no Name / of the last School the child attended: Signature of Custodian / Guardian Date

REQUEST FOR RELEASE OF STUDENT RECORDS Berea City School District 390 Fair Street Berea, OH 44017 Phone: 216-898-8300 Fax: 216-898-8551 Previous School Name/ It is requested that an official copy of the student records of: Student s Name Birth date Last Grade Attended Be released to: Berea City School District Central Registration 390 Fair Street Berea, OH 44017 This student started at on (Name of BCSD School attending) (Official Start Date) Please include the following information: Has this student been expelled from your school district? If yes, please provide expulsion dates and copy of expulsion letter. Academic Grades Grades to Withdrawal Date Grades for previously completed marking period (sports eligibility) Standardized text scores (achievement, competency, etc.) Proficiency Test Scores Attendance Records Health/Immunization Records Psychological Reports (if any) Individual Education Plan (I.E.P.) / Multifactored Evaluation Speech/Hearing/Language Evaluations School Profile explaining credits and grading system ALL OF THE ABOVE Other (please specify) Signature of Parent or Legal Custodian or Student (if legal age) School Official / Title Parents, custodians or legal age students may inspect the records to be released or transferred.