ENROLLMENT FORM City of St. Charles R-VI School District Student ID#: Bldg: In-District Transfer MOSIS #: Enrollment Grade: Gender: M F Student s Legal Name : Last First Middle Transportation home: Bus Walk Car Daycare Other In case of early release due to inclement weather, how will student get home? Bus Walk Car Daycare (NO Latchkey on these days) Other Please list brothers and/or sisters of student First and last name Age Living @ home School Attending Home Language: Birth date: / / Social Security #: Race: Asian, Black/African American, American Indian/Alaska Native, Month Day Year (optional) Pacific Islander/Native Hawaiian, White (circle all that apply) (optional) Information used to meet governmental reporting requirements only. Start Date: / / State and Country of birth: If student was not born in US, when did student move to US? Month Day Year State Country Student s primary address: If student does not live with both parents, what is the secondary address of mother/father? Primary phone # to use for Alert Now: ( ) Yes Yes Yes No No No Parent Name Street City Zip Alert Now is an automated phone message system used to alert parents of important school information such as school closings, etc. Parent/Guardian email: Is student of Hispanic ethnicity? Yes No Please indicate if student s parents are: Divorced / Separated (circle one) Who has primary custody? Mother / Father / Guardian / Children s Division (circle one) Please indicate if student is currently in foster care: yes no (circle one) Name of any person prohibited by court action from having contact with student. Court documents must be provided. Page 1 of 3 Contact Name Mother Father Contact Type fill in other type Step parent/guardian Emergency Living with? (circle one) Full-time Part-time No Full-time Part-time No Full-time Part-time No Full-time Part-time No Phone # and type (Cell, work, etc.) Phone # and type (Cell, work, etc.) Phone # and Type (Cell, work, etc.)
School(s) previously attended (Begin with most recent) Address Street City State Zip School Phone # Grade(s) Attended Dates Attended From To ( ) ( ) ( ) ( ) Other: At previous school(s) attended, student (please indicate all that apply): Was in a Special Education program Has an IEP Was referred or recommended for Special Education testing Yes No Yes No Yes No Full-time Part-time No Was in a Remedial Math or Language Arts program Yes No Was in a Gifted Program Yes No Was in ELL or ESOL Program Yes No Has a 504 Plan Yes No School Districts in Missouri are required to release student directory information to any one who requests the information in writing. Directory information is information contained in an education record of a student that generally would not be considered harmful or an invasion of privacy. For a complete definition; please refer to the Student Code of Conduct or District Policy. Parents may refuse such release of information. Initial if permission is denied: Was English the first language this student learned? Yes No Did your child learn English as a second language? Yes No Does your child use a language other than English? Yes No If Yes, what language? Which language does this student use most often when speaking to friends? English Other If Other, what language? Which language does this student use most often when speaking to his/her parents? English Other If Other, what language? Is a language other than English used in your home? Yes No If Yes, what language? In the last 3 years, has the parent,/guardian worked or is currently working in any of these areas. If so, which ones? Planting or harvesting crops Feeding poultry, gathering eggs, working in a hatchery Processing meat, poultry, fruit, vegetables, dairy products Milking cows on a dairy farm Working in a nursery Commercial fishing or working on a fish farm Growing and tending to trees to be sold If you checked any box above, did you move to seek or obtain that job? Yes No Page 2 of 3
We do not have permanent housing of our own at this time, due to economic conditions (living in a shelter, a hotel, or with friends) Yes No If yes, please complete the following: Are you sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason? Yes No Explain: Are you currently residing at a hotel, motel, in a car, or at a campsite because your home has been damaged or because of economic reasons? Yes No Are you currently living in a shelter? Yes No Are you currently living in a temporary housing arrangement due to economic hardship? Yes No Student Conduct: Based on regulations of the MISSOURI SAFE SCHOOLS ACT, the following information must be provided. Has student ever been suspended or expelled from school? Yes No If yes, date of expulsion: Total length of suspension: days. Please provide explanation: Has student been charged with or currently under investigation for any of the following? Check all that apply. First degree murder Second degree murder First degree assault Forcible rape (as it existed prior to 8/28/2013) or rape in the first degree Forcible sodomy (as it existed prior to 8/28/2013) or sodomy in the first degree Statutory rape Statutory sodomy Robbery in the first degree Distribution of drugs to a minor Arson in the first degree Kidnapping, when classified as a class A felony I am the parent/legal guardian of and I am providing this affidavit in support of the enrollment of my child in the St. Charles City School District. My child is not currently under suspension or expulsion from any school district he/she has previously attended. I understand that it is a criminal offense (Class B Misdemeanor-Section 167.23RSMO) to give false information concerning prior disciplinary action taken against my child. I also understand that if this school district admits my child based on false information which I gave, I may be required to pay the school district for its costs in educating my child. (Section 165.020RSMO) Parent/Guardian signature: Must be signed in presence of notary. Date: Subscribed and sworn to before me, a notary public on the day of,. Notary Signature: Notary Stamp Enrollment Form Updated 02-15-2018 Page 3 of 3
Name: Last First M.I. Birth Date: Male Female Return this form to the School Nurse. Please complete the following information which will assist us in providing your child's school health services and educational needs in a safe and effective manner. (Please have several updated contacts and phone numbers listed in case of emergencies- we must be able to reach someone at all times.) Address: Lives with: Parent E-mail: Father s Name: Work Phone: Cell Phone: Alt Phone: Mother s Name: Work Phone: Cell Phone: Alt Phone: Current Doctor: Phone: Fax: If your child has any of the conditions below marked with an * PLEASE SEE THE SCHOOL NURSE *Life threatening Allergy? NO / YES *STUDENT MUST PROVIDE EMERGENCY MEDICINE.* *Food Allergy? NO / YES EX: (Peanut) Drug Allergy? NO / YES NOTES: Bee Sting Allergy? NO / YES Other Allergy? NO / YES *Asthma? NO / YES *Diabetes? NO / YES *Epilepsy/Seizures? NO / YES Heart Condition? NO / YES Physical Restrictions? NO / YES Physical Handicap? NO / YES Condition that prevents full participation in PE?: ** Doctor note required List surgeries (operations): Emotional conditions: Other health info / concerns: School Sports/Activities or circle THE FOLLOWING REGARDING HEALTH CONCERNS Eyes: glasses (reading distance ); contacts ; crossed ; lazy eye ; difficulty seeing ; color blindness. Ears: frequent infections ; tubes ; hearing difficulty (explain) Hearing aid (right left ) Wear at school? NO YES Medications: Takes daily medications at home? NO YES Takes daily medications at school? NO YES List current medicine taken at home-include dosage and time of day given: (1): (2): If student requires medication at school please obtain the appropriate form from the school nurse or the school website. Medication will be discarded after the last day of school if not picked up. *All updated immunizations require signature of physician or health department with day, month and year. The information provided above will be shared as needed with school staff to provide for the health and safety of my child. I authorize my child s health care provider and designated provider of health care in the school setting to discuss my child s health concerns and/or exchange information pertaining to their health. (I may withdraw my authorization at any time by contacting the school). If I or an authorized emergency contact cannot be reached in an emergency, I authorize school staff to obtain emergency medical care as needed. I understand I will assume financial responsibility for any medical services rendered. BY SIGNING BELOW I UNDERSTAND AND AGREE TO ALL TERMS LISTED ABOVE AND AGREE THAT ALL INFORMATION I PROVIDED IS COMPLETE AND ACCURATE. Signature of legal parent/guardian School: Year : Grade: Emergency Contact / Relationship Phone 1 Phone 2 Emergency Contact / Relationship Phone 1 Phone 2 1. 3. 2. 4. Date (Revised 8/2016)
At times, students may be photographed, interviewed, or recorded during school activities and events to be used by the district in district publications, district newsletters, on the district s website and/or in the local media. I do not give permission for my child s photograph/interview/recording/project related to school activities and events to be used by the district and/or local media. Yes, I give permission for my child s photograph/interview/recording/project related to school activities and events to be used by the district and/or local media. Signature of Parent/Guardian Date Student s Name (Please Print) Student s School Student s Teacher Return this form to: by St. Charles School District 400 North Sixth Street St. Charles, MO 63301 Revised 2/13/2018
APPLICATION FOR TRANSPORTATION 2018-2019 SCHOOL YEAR Please fill out all mandatory fields (*). For Office Use Only Route #: Student #: Approved: Not Approved: *Student s Last Name *First Name Middle Initial Nickname *Street Address *City *State *Zip Code *Home Phone *Cell Phone Work Phone Parent E-Mail Address *Nearest Street Corner *Grade *School Building Siblings in District (Name, Age, School) *Emergency Contact Person/Number It will be necessary for students who desire to ride the bus to complete this application and return it to the Teacher or Principal. Students grades K through 12 must live one mile or more from their assigned school to qualify for bus transportation. Students will be transported using the most efficient routes possible (which could change). The most updated routes can be found on our district website: www.stcharlessd.org. Special Ed Wheelchair Note to Parents: The City of St. Charles School District use this information in the event of an emergency. Please notify the District if you have any objections to providing this information.
Residency / Enrollment Requirements Find which description best fits your Living Conditions and then provide the necessary documentation when you submit your enrollment packet Description Documentation Residency/Affidavit/Waiver When to Enroll? Lives w/parents Residency proof required along with other Upon submission of in-district residency checklist documents required enrollment documents Lives with parent in district at someone else s residence (doubled up) Residency proof (affidavit Part 1) required Upon submission of required along with other residency checklist documents enrollment documents unless living there because of hardship -- then handle as homeless Homeless Affidavit if relevant along w/other residency checklist documents If living out of car, etc. If living in shelter, verification from shelter Immediately Immediately Immediately Lives w/relatives in district Affidavit of Relative Caregiver, Other Upon submission of required without parent residency checklist documents, enrollment documents (Grandparents/Older Sibling) unless parents not contributing to child s support then may be handle as homeless Lives with resident without parent Affidavit (Part 2) of residency of person they are Upon submission of required living with; other residency checklist documents, enrollment documents Limited Guardianship from the courts is required. unless parents not contributing to child s support -- then may be handled as homeless *Contact Julie McClard s office for any enrollment that involves Homeless, Foster, or Unaccompanied Youth students. February 13, 2018
RESIDENCY ENROLLMENT CHECKLIST (To be used as a guide by Registrar/School Official-Not to be kept in student file-informational only) Name of Parent/Guardian Address City/State Zip Telephone Number - Home Work Name of Student Address City/State Zip Telephone Number Date of Birth For address verification (Parent/Legal Guardian) (Attach copy of document) provide at least one document from each of the following lists: List A Current Rental contract Current Real Estate Contract Current Real Estate Tax Receipt Current Mortgage Statement Current Homeowner s Policy List B Current/ Unpaid Utility Bill Current Voter Registration Card Current Bank Statement Current Credit Card Statement Current Personal Property Tax Receipt Welfare, Social Security, or Other Legal Court Document The primary criterion for residency is the family s/child s actual domicile. The district has the right to request additional proofs at any time or to employ other means to verify residence. Any person who knowingly submits false information to satisfy any requirement of this section is guilty of a class A misdemeanor. In addition to any other penalties authorized by law, a district board may file a civil action to recover, from the parent/legal guardian of the pupil, the costs of school attendance for any pupil who was enrolled at a school in the district and whose parent/legal guardian filed false information to satisfy any requirement of this section (167.151RSMo). Basis for Admission of Student (167.020 RSMo) Resides with parent in the school district Resides with legal guardian in the school district (Copy of court ordered guardianship must be attached. A guardian may be appointed for the sole and specific purpose of school registration (SB944)). Resides with a military guardian in the school district (SB944). Revised 2/13/2018
Homeless child (person less than 21 years of age who lacks a fixed, regular and adequate nighttime residence), including a child who is: A. Is sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason; is living in motels, hotels, or camping grounds due to lack of alternative adequate accommodations; is living in emergency or transitional shelters; is abandoned in hospitals; or is awaiting foster care placement; B. Has a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings; C. Is living in cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations, or similar settings; and D. Is a migratory child or youth who qualifies as homeless because the child or youth is living in circumstances described in subdivisions (A) to (C) of this subsection. *School must verify Homeless status with the District s Homeless Coordinator Homeless Coordinator verification Special circumstances (Section 167.151, RSMo): A. an orphan B. one parent living C. parents do not contribute to the student s support D. agriculture (all four of the following conditions must be met: owns real estate of which 80 acres or more are used for agricultural purposes, parent's residence is on the real estate, at least 35% of the real estate is in the district, parent notified district on or before June 30 that student would be attending) Parent is a teacher under contract with the district (Board policy required-section 167.151, RSMo, 168.151, RSMo) Parent is a regular employee with the district (Board policy required-section 163.011, RSMo) Other exemptions to the residency requirements (Section 167.020.6, RSMo) Attending school not in the pupil s district of residence as a participant in an interdistrict transfer program established under a court-ordered desegregation program A ward of the state and has been placed in a residential care facility by state officials* Has been placed in a residential care facility due to a mental illness or developmental disability* Has been placed in a residential facility by a juvenile court* Has a disability identified under state eligibility criteria if the student is in the district for reason other than accessing the district s educational program *The district of residence will be billed for the local tax effort for the student(s) attending under these circumstances. Revised 2/13/2018
Date of Student Admission Student denied admission. Date of denial Waiver requested. Date of request WAIVER INFORMATION Waiver is only applicable if student is not residing with parent or legal guardian, but is living in district. (Parent/guardian must complete a waiver of Residency Request form, Affidavit Part I (notarized), Affidavit Part II (notarized) and submit to district administration for consideration.) Waiver requested by: A. Parent B. Legal guardian C. Student (at least 18 years old) D. Other a. Name of person/relative student resides with b. Relationship c. Address d. City/State/Zip e. Address Verification f. Reason why student is living with person/relative Other reasons showing hardship or good cause Hearing Date (must be within 45 days of request) Student admitted pending decision on waiver request Date student admitted Waiver granted. Date Waiver denied. Date Students attending school pursuant to the above information may be counted for state aid purposes. Nonresident students who may enroll and are not counted by the district for state aid. Tuition Tax credit tuition-any person who pays a school tax in any other district than that in which he resides may send his children to any public school in the district in which the tax is paid and receive as a credit on the amount charged for tuition the amount of the school tax paid to the district (Section 167.151(3), RSMo) Transportation Hardship as assigned by the commissioner of education (Section 167.121, RSMo) Attending a regional or cooperative alternative education program or an alternative education program on a contractual basis (Section 167.020.6, RSMo) Revised 2/13/2018