Required Documents to Complete Student Enrollment & Registration: Shot record on GA Certificate of Immunization (Form 3231)

Transcription

1 VCS ENROLLMENT & REGISTRATION CHECKLIST Required Documents to Complete Student Enrollment & Registration: VCS Student Registration Packet a. Student Registration Form b. Parent Occupational Survey c. Home Language Survey d. Student Non-Recruitment Verification Certified/Official birth certificate of child Social Security card Shot record on GA Certificate of Immunization (Form 3231) Certificate of Eye, Ear, Dental Examination (Form 3300) Proof of Residence within the school district Minimum of TWO current documents from the following list is required for all students: a. Current utility bill with parent s name and address (MUST BE ONE FORM OF PROOF); Utility bills can include: electricity, water, gas, or cable Must be current within past 30 days b. Rental agreement with parent s name and address; and/or c. Mortgage payment document with parent s name and address

2 FOR OFFICE USE: Grade/Teacher / Infinite Campus ID #assigned Valdosta City Schools Student Registration GTID# Student Name: Last Name First Name Middle Name (suffix: Jr., III) Birthday: Birth Place: U. S. Citizen? Yes No Month/Day/Year City State (Check One) Student Address: Street City State Zip Student Address: Not Applicable Primary Contact Phone: (This number will be used for automated calls/messages) County of Residence: Birth Country: Start Date in US Schools: Month/Day/Year Sex: M F Ethnicity (Complete Part A and B): (Circle One) Part A: Is the student Hispanic/Latino? (choose only one) No, not Hispanic/Latino Yes, Hispanic/Latino (a person of Cuban, Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish Culture or origin.) Part B: What is the student s race? (choose one or more) American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Student resides with: Both Parents Mother Father Foster Parent Legal Guardian Parent/Guardian 1: Last Name First Name Middle Name ( suffix: Jr., III) Relationship to Child: Cell Phone: Address: Home Phone: (If different from Student Address) Address: Employer: Work Phone: Parent/Guardian 2: Last Name First Name Middle Name ( suffix: Jr., III) Relationship to Child: Cell Phone: Address: Home Phone: (If different from Student Address) Address: Employer: Work Phone: Parent/Guardian is Active Duty in US Armed Forces? Yes No Parent/Guardian is employed on a military base? Yes No VCS REGISTRATION (OVER) PAGE 1 OF 2

3 School Last Attended: Name of School City State Phone Number Has your child ever been enrolled in Valdosta City Schools: Yes No If yes, list name of school: List Preschool/Pre-K your child attended: Has your child received any of the following special services in previous school or VCS? Check all that apply. Special Education Speech Gifted ESOL Migrant SST/504 Remedial List any allergies or current medication: List other siblings attending VCS that reside with this student: Emergency Contacts: Name & Relationship to Student Phone Name & Relationship to Student Phone How will your child get home? Bus Car Walk Day Care Van Other: AUTHORIZATION TO ENROLL AND WITHDRAW YOUR STUDENT For school purposes, and/or Parent/Guardian 1 Parent/Guardian 2 shall be designated as the enrolling parent(s)/guardian(s). I/We understand once an enrolling person(s) is designated, school officials are required by law to honor said designation until the same is changed by the undersigned in writing, or a Court Order is entered meeting the requirements of OCGA Once an enrolling person(s) is designated, this designation is not affected by a change on the emergency contact card. Parent/Guardian Signature Date AFFIDAVIT OF RESIDENCE I/We, certify, swear and/or affirm as follows that: Parent/Guardian Signatures 1. I am the parent/court appointed guardian of the child listed above. 2. The child listed above resides with me full time at the address listed above. 3. I understand that I must immediately notify Valdosta City Schools if I change residence or if the child listed above should change residence. 4. The above information is to the best of my knowledge and belief, true, correct, and complete. 5. I understand that representatives of Valdosta City Schools may visit my home to verify residency, and I hereby voluntarily consent to such visits. 6. Representatives of Valdosta City Schools may verify residency through property management, homeowners, landlords, and/or utilities, and I hereby voluntarily consent to such verification. 7. I understand that a student enrolled in Valdosta City Schools under falsified information is illegally enrolled and will be immediately withdrawn from school. 8. I understand that false swearing is in violation of the laws of the State of Georgia and is punishable by a fine of not more than $1,000 or by imprisonment for not less than one of more than five years, or both. OCGA VCS REGISTRATION PAGE 2 OF 2

4 Richard Woods, Georgia s School Superintendent Educating Georgia s Future 1854 Twin Towers East 205 Jesse Hill Jr. Drive Atlanta, Georgia An Equal Opportunity Employer

5 Student Name Birth Date Grade Home Language Survey Dear Parent or Guardian: In order to provide your child with the best possible education, we need to determine how well he or she speaks and understands English. This survey assists school personnel in deciding whether your child may be a candidate for additional English language support. Final qualification for language support is based on the results of an English language assessment. Thank You 1. Which language does your child most frequently speak at home? 2. Which language do adults in your home most frequently use when speaking with your child? 3. Which language(s) does your child currently understand or speak? 4. If possible, would you prefer notice of school activities in a language other than English? Yes No If yes, which language? Signature of Parent/Guardian/Other Date

6 Student: Parents/Guardians: Please read the following information carefully and sign in the appropriate space at the end of the document. Recruiting and undue influence is defined as the use of influence by any person connected directly or indirectly with a GHSA school to induce a student of any age to transfer from one school to another, or to enter the ninth grade at a member school for athletic or literary competition purposes, whether or not the school presently attended by the student is a member of the GHSA. (a) The use of undue influence to secure OR retain a student for competitive purposes is prohibited, and shall lead to penalties being assessed against either school. NOTE: This violation may cause the student to forfeit eligibility for one year from the date of enrollment. (b) Evidence of undue influence includes, but is not limited to: 1. personal contact initiated by coaches, boosters, or other school personnel in an gifts of money, jobs, supplies or clothing 2. free transportation 3. free admission to contests 4. an invitation to attend practices and/or games 5. a social event (other than official school wide Open House program) specifically geared for prospective athletes 6. free tuition beyond the allowable standards found in by-law a coach asking a prospective student for contact information. A student athlete transferring from one member school to another shall be ruled ineligible for one year because of undue influence if it is proven that: (a) the coach of the receiving school coached an out-of-school team on which the athlete played prior to the transfer; or (b) the coach at the receiving school acted as a private athletic instructor for the transferring athlete, regardless of whether the coach was paid for his services and/or expertise; or (c) the player who played for a coach at a former GHSA school followed that coach when he/she moved to another GHSA school (This is not applicable to dependent children of the coach.) (d) The situations cited in the by-laws are considered to be violations even if a bona fide move has occurred, and the hardship appeal procedures are available for the demonstration that undue influence has not occurred. A booster shall be considered to be an extension of the school and must abide by all rules applied to coaches and other school personnel. The following persons or groups may be considered boosters: members of the school s Booster Club; alumni; parents; guardians; relatives of a student or former student; financial donors; or donors of time and effort. By signing below I am verifying that none of the conditions stated above have influenced my decision to enroll my child in Valdosta City Schools. Parent/Guardian s Signature Printed Name of Parent/Guardian Date 4/17

7 Rev. 07/2014 Georgia Department of Public Health Form 3231 CERTIFICATE OF IMMUNIZATION (Fill in X) Child's Name (Last name first) Birthdate Date of Expiration (Optional) Parent/Guardian Name (Last name first) (Next required immunization or review of medical exemption due.) Complete For K through 6th Grade Child must be 4 years and have met all requirements for school attendance. (Fill in X) Complete For 7th Grade or higher Fulfills requirements K through 6th grade AND must have Tdap and MCV4 documented Unless specifically exempted by law, Georgia law (O.C.G.A ) requires a certificate on file for each child in attendance in any school or child care facility in Georgia with penalties for failure to comply. Detailed instructions for this form and immunization requirements by age are spelled out in policy guides 3231INS and 3231REQ distributed by the Georgia Immunization Office. VACCINE DATE DATE DATE DATE DATE DATE MM DD YY MM DD YY MM DD YY MM DD YY MM DD YY MM DD YY Total Doses Diagnosed Serology + History Med. Exemption Required Vaccines for School or Child Care Attendance DTP,DTaP, DT,Td Polio Hepatitis B Tdap MCV4 HIB (Under Age 5) PCV (Under Age 5) Measles Mumps Rubella Hepatitis A (Born on/after 1/1/06) Varicella Recommended Vaccines (For Information Only) Rotavirus HPV (3 doses) Influenza Td (booster) Notes: A licensed Georgia physician, Advanced Practice Registered Nurse, Physician Assistant or qualified employee of a local Board of Health or the State Immunization Office is responsible for the content of this certificate. All dates must include month, day and year. In cases of natural immunity or Medical Exemption, the 4 digit year of infection, test or exemption must be filled in the appropriate box(es). The certificate is NOT valid without name and birthdate of the child, date of expiration OR "X" in Complete for School Attendance box, legible name and address of the physician, Advanced Practice Registered Nurse, Physician Assistant or health department, certified by signature and a date of issue. A school or facility official is responsible for keeping a current valid certificate on file for each child in attendance. A certificate must be replaced within 30 days after expiration. When a child leaves or transfers to another facility, the Certificate of Immunization should be given to a parent/guardian or sent to the new facility. Printed, Typed or Stamped Name, Address and Telephone # of Licensed Physician or Health Dept. Certified by (Signature/Signature Stamp) Date of Issue

8 Georgia Department of Public Health Form 3300 Certificate of Vision, Hearing, Dental, and Nutrition Screening FILE THIS FORM WITH THE SCHOOL WHEN YOUR CHILD IS FIRST ENROLLED IN A GEORGIA PUBLIC SCHOOL SCREENER CONTACT INFORMATION IS REQUIRED Parent/ Guardian Name: first middle last Parent/ Guardian Contact Information: Daytime phone number: Evening phone number: Cell phone number: VISION Unable to screen (explain why below) Uses corrective lenses Worn for testing Passed (20/30 in each eye for age 6 and above, 20/40 in each eye for below age 6) Needs further evaluation Under professional care (explain below) Screening completed by: Physician Local Health Department Optometrist Prevent Blindness Georgia employee School Registered Nurse HEARING Unable to screen (explain why below) Uses hearing aid / assistive device Passed at 500, 1000, 2000, and 4000 Hz with audiometer at 20 or 25 db Needs further evaluation Under professional care (explain below) Screening completed by: Physician Local Health Department Audiologist Speech-Language Pathologist School Registered Nurse Child s Name: first middle last Date of Birth: / / Gender: Male Female Child s Home Address: street city state zip code county DENTAL Unable to screen (explain why below) Normal appearance Needs further evaluation Emergency problem observed Under professional care (explain below) Screening completed by: Physician Dentist Local Health Department Registered Nurse Registered Dental Hygienist School Registered Nurse PLEASE SEE THE INSTRUCTIONS ON THE BACK OF THIS FORM NUTRITION Unable to screen (explain why below) Height: Weight: BMI: BMI%: 5 th to 84th percentile - Appropriate for age < 5 th percentile - Needs further evaluation 85 th percentile - Needs further evaluation Under professional care (explain below) Screening completed by: Physician Local Health Department Registered Dietician School Registered Nurse Screener s Signature Date I certify that this child has received the above screening. Contact Information: Screener s Signature Date I certify that this child has received the above screening. Contact Information: Screener s Signature Date I certify that this child has received the above screening. Contact Information: Screener s Signature Date I certify that this child has received the above screening. Contact Information: FOR SCHOOL SYSTEM ONLY Follow up for further evaluation 1 st attempt 2 nd attempt Actions reported (if any) Vision Hearing Dental Nutrition Student support services initiated on: Screeners Comments: DPH Form 3300 Rev. 2013