SHENENDEHOWA                   
CENTRAL SCHOOLS                                                                             Student Registration Form

Student Name: _____________________________________________________   Reg. Date: _________________

Address Cell: ________________  Address School Assignment: Elem: __________ ____ Middle: _________________

Bus Route: IN/___________   OUT/__________

CUMULATIVE FOLDER INFORMATION/Student Name Only________________________________________
                                                                                                                                  Office Use Only
(Please Print)
________________________________________________________________________________

PRIMARY HOUSEHOLD PARENT/GUARDIAN INFORMATION
(Only list those adults living in the household with the child(ren) listed on page 2)

1.  Father / Male Guardian _______________________________________________________________________
                                                   Last Name                                   First Name                            M.I.     

Cell Phone Number: ______________________________    Pager Number: ________________________________

Work Number: __________________________________   Email Address: ________________________________

Employer:  __________________________________________      Occupation: _____________________________

Employer Address: ____________________________________________________________________________

2.  Mother / Female Guardian ___________________________________________________________________
                                                         Last Name                                   First Name                            M.I.     

Cell Phone Number: ______________________________    Pager Number: ________________________________

Work Number: __________________________________   Email Address: ________________________________

Employer:  __________________________________________      Occupation: _____________________________

Employer Address: ____________________________________________________________________________

Residential Address:

___________________________________________________________________________________________
House #         Street                                                                       City/State/Zip                                          Apt. #

Mailing Address (if different from above)_____________________________________________________________

Home Phone________________________________________________________________

                                                                                                            

ALL CHILDREN LIVING IN PRIMARY HOUSEHOLD UNDER THE AGE OF 21

First

 

Middle
Name

Last

 

SEX

M/F

Date of Birth

Relationship to Adults in HH

Race / Ethnic
Group

S.S. #

 

School

 

Grd

 

Student ID #
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Relationship of Household Adults to Children Race/Ethnic Group Codes: Please list one only (required by No Child Left Behind Federal Legislation
FA -Bio/Legal Father MO -Bio/Legal Mother A -Asian
SF -Stepfather SM -Stepmother B -Black or African American
MG -Legal Male Guardian FG -Legal Female Guardian H -Hispanic or Latino
FF -Foster Father FM -Foster Mother I -American Indian or Alaskan Native
RM -Other Male, Related** RF -Other Femal, Related** M -Multiracial
UM -Other Male, Unrelated** UF -Other Female, Unelated** P -Native Hawaiian/Other Pacific Islander
S -Self     W -White


**If RM, RF, UM, or UF, please explain relationship with child:____________________________________

Child’s Place Of Birth___________________________________________________________________                                                                 City                                State                         
Was your child born outside the United States?  No _____    Yes ____      If yes, please answer questions below.
What country was your child born in? ________________   Date of Initial entry into the United States:_________
Number of years in US schools: ______________ Number of years in school outside the US:_________________

Did the student(s) previously attend Shenendehowa Central School?      Yes_________ No__________
If yes:   Name of Shenendehowa School_____________________________________Date Left_____________

Name of School Last Attended_________________________________________________________________
Address and Phone_________________________________________________________________________

Has your child ever repeated a grade?  _______ Yes _______  No      If yes, which grade: _______________

High School Student:  Date entered 9th grade -______________________

 

Is English the only language spoken at home?                _____yes        ______no

If no, what other language does your family speak? ____________________________________________

Any legal custodial restrictions?  ______  Yes  ______  No   If yes, please attach court documents.

Important Note Regarding Release of Students from School:

The school district shall presume that either parent of a student has authority to obtain the child’s release from school.  However, a student shall not be released to a non-custodial parent if the district has been provided with a certified copy of a legally binding instrument, such as a court order or decree of divorce, separation or custody, that indicates the non-custodial parent does not have the right to obtain such release.

Special Needs of the Child: Has your child ever received special education services?

______  Speech / Language Therapy      ______  Occupational Therapy           ______ Physical Therapy

______ Consultant Teacher                   ______  Self-Contained Classroom     ______  Resource Room

______  BOCES                                    ______  504 Plan                                ______  Declassified

Other special needs: ______________________________________________________________________________

Is Shenendehowa CSD currently transporting your child to private school?  ______ Yes ______  No

If yes, please cancel my application for non-public transportation for the following student(s):

Student(s) Name:                                                                                                                                                       

Parent Signature: _______________________________      Date: __________________________

Names, addresses and phone numbers of two people with whom you have made arrangements to take responsibility for your child in the event you cannot be reached.

Name                                                                     Name                                                                        

Address                                                                  Address                                                             

Daytime Phone #                                                  Daytime Phone #                                                           

Parent Statement:

I certify that the above information is true and correct.  Any misinformation regarding residency may result in being billed to cover the cost of instruction and/or exclusion from attending the Shenendehowa Central School District.

Parent Signature:  __________________________________________    Date: ________________