YORK SUBURBAN SCHOOL DISTRICT – REGISTRATION FORM

YORK SUBURBAN SCHOOL DISTRICT – REGISTRATION FORM
DATE:_____________
STUDENT INFORMATION
LAST NAME:______________________________ FIRST:___________________________ MIDDLE:_____________________ SUFFIX________
NICKNAME:__________________
BIRTH DATE:_____/______/______
GENDER: MALE
FEMALE
GRADE:_______
ETHNICITY (CIRCLE ONE): WHITE BLACK (NON HISPANIC) HISPANIC AMERICAN INDIAN ASIAN/PACIFIC ISLANDER ALASKAN
HOUSEHOLD ADDRESS (PRIMARY): ______________________________________________________________________APT #: ________
CITY:_________________ STATE: PA ZIP:__________ PRIMARY PHONE: (
STUDENT ENTRY DATE INTO USA:_______________
)______________________UNLISTED:
YES
NO
STATE START DATE:_____________
STUDENT ENTRY DATE INTO USA SCHOOL______________
LANGUAGE SPOKEN AT HOME _________________
PRIMARY HOUSHOLD MEMBERS(LIST EVERYONE LIVING IN THE HOME WITH THE STUDENT)
LAST NAME
FIRST NAME
BIRTHDATE
RELATION TO STUDENT
/
/
/
/
/
/
/
/
/
/
PARENTS/GUARDIANS NOT LIVING IN PRIMARY HOUSEHOLD (SECONDARY)
LAST NAME
FIRST NAME
RELATION TO STUDENT
RECEIVE MAILINGS
YES
NO
YES
NO
SECONDARY ADDRESS: ______________________________________________________________________APT #: _____________
CITY:___________________________ STATE: ___________ ZIP:________________
PHONE: (
)
UNLISTED:
YES
JOINT CUSTODY:
YES
NO
NO
CONTACT INFORMATION DURING SCHOOL HOURS – 7:30AM TO 4:30PM
FATHER/GUARDIAN’S DAYTIME/WORK PHONE : (______)______________________EXT:________ CELL: (_______)____________________
EMAIL:___________________________________________________
MOTHER/GUARDIAN’S DAYTIME/WORK PHONE : (______)_______________________EXT:________ CELL: (______)____________________
EMAIL:___________________________________________________
PREVIOUS SCHOOL INFORMATION
NAME OF SCHOOL DISTRICT :_______________________________________________________PHONE:(_____)______________________
BUILDING OF ATTENDANCE:____________________________________
SCHOOL ADDRESS:______________________________________CITY: _______________________ STATE:____________ZIP: ______________
SCHOOL OFFICIAL/COUNSELOR:______________________________________ FAX: (_____)_________________________________________
WITH THE FOLLOWING PARENT/GUARDIAN SIGNATURE, I STATE THE ABOVE INFORMATION TO BE TRUE
__________________________________________________________
(Parent/Guardian Signature)
Form #1R 1/26/09
YORK SUBURBAN SCHOOL DISTRICT – REGISTRATION FORM
Pg. 2
OFFICE USE ONLY:
BUILDING OF ATTENDANCE: _____________________________________
STUDENT NO:______________________ STUDENT NAME:______________________________________________
ENTRY CODE: E____ or R______
ENTRY DATE: ______________________ GRADE: ___________
H.R. TEACHER:______________________________________ ROOM #:_____________
DISABILITY/EXCEPTIONALITY CODE: ________
GUIDANCE COUNSELOR: ______________________ COUNSELOR # :______
DISTRICT START DATE:____________ SCHOOL START DATE:____________
PA SECURE ID#:_________________________________________
TRANSPORTATION:
BUS STOP NAME: ____________________________________________________ BUS #:________
RESIDENCY:
NON-RES: ___________ TUITION:___________ FOSTER:_________ PLACEMENT PAPERS: _________________
Form #1R 1/26/09
YORK SUBURBAN SCHOOL DISTRICT – EMERGENCY INFORMATION FORM
DATE:_____________
STUDENT INFORMATION
LAST NAME:_____________________________ FIRST:__________________________ MIDDLE:__________________SUFFIX:________
NICKNAME:______________ GENDER: MALE
FEMALE
BIRTH DATE:_______/__________/_________ GRADE:__________________
STUDENT RESIDES AT: _________________________________________________________APT #:________
CITY:___________ STATE:_____ ZIP CODE: __________
HOME PHONE: (_______)______________________________ UNLISTED: YES
NO
EMERGENCY INFORMATION( NON-HOUSEHOLD CONTACTS):
(PLEASE LIST SOMEONE WHO LIVES LOCALLY AND HAS RESPONSIBILITY FOR YOUR CHILD.)
CONTACT NAME:_______________________________________RELATIONSHIP:_____________________________
DAYTIME PHONE:_______________________CELL PHONE:_____________________________
CONTACT NAME:_______________________________________RELATIONSHIP:_____________________________
DAYTIME PHONE:_______________________ CELL PHONE :____________________________
PHYSICIAN:___________________________________________________________PHONE:__________________________________
HOSPITAL (PLEASE CIRCLE ONE): MEMORIAL OR
YORK
PERMISSION TO TRANSPORT: YES
NO
SENSITIVITY TO
DRUGS:_________________________________________________________________________________________________________
SPECIFIC HEALTH
PROBLEMS:_____________________________________________________________________________________________________
WITH THE FOLLOWING PARENT/GUARDIAN SIGNATURE, I STATE THE ABOVE INFORMATION TO BE TRUE AND ALSO GIVE
PERMISSION FOR EMERGENCY TREATMENT FOR MY STUDENT:
________________________________________________
(PARENT/GUARDIAN SIGNATURE)
Form #2 EC 1/26/09
YORK SUBURBAN SCHOOL DISTRICT
PROOF OF RESIDENCY FOR ENROLLMENT
STUDENT INFORMATION:
Name of Student 1 _____________________________________ Grade ____________
[ ] Valley View [ ] East York [ ] Indian Rock [ ] Middle School [ ] High School
Name of Student 2 _____________________________________ Grade ____________
[ ] Valley View [ ] East York [ ] Indian Rock [ ] Middle School [ ] High School
Name of Student 3 _____________________________________ Grade ____________
[ ] Valley View [ ] East York [ ] Indian Rock [ ] Middle School [ ] High School
PARENT/GUARDIAN INFORMATION:
Name of Parent(s)/Guardian: _______________________________________________
Address_________________________________________________________________
Street Address
City
State
Zip
Home Phone Number __________________ Work Phone Number _________________
Current Residence (If Different from Above):
________________________________________________________________________
Street Address
City
State
Zip
Attach one of the following to substantiate residency in the district:
[
[
[
[
]
]
]
]
Utility Bill
Pennsylvania Department of Transportation Identification or Drivers License
Pennsylvania Department of Transportation Vehicle Registration
Copy of sales agreement/contract with settlement date, lease rental agreement, rent
receipt, or other similar document which verifies intent to establish residency.
Through my signature, I/we grant the school district permission to investigate the above
information that I/we have presented in this residency affidavit for confirmation and factual
accuracy. If investigation discloses that these statements are false or that you are not a legal
resident of the York Suburban School District, you will be liable for tuition for the period of time
of non-residency.
Signature of Resident Parents/Guardians: ______________________________________
Date: _____________________
______________________________________
This form must be completed for all students prior to enrolling in the district. Residency
exceptions (e.g. Future residents, students residing with persons other than parent or legal
guardian) must be processed through the Superintendent’s Office.
YORK SUBURBAN SCHOOL DISTRICT
SWORN STATEMENT
LEGAL AUTHORITY – Section 1034-A Sworn Statement—(A) Prior to admission to any school
entity, the parent, guardian or other person having control or charge of a student shall, upon
registration, provide a sworn statement or affirmation stating whether the pupil was previously
suspended or expelled from any public or private school of this Commonwealth or any other state
for an act or offense involving weapons, alcohol or drugs, or for the willful infliction of injury to
another person or for any act of violence committed on school property. The registration shall be
maintained in the student’s disciplinary record. (B) Any willful false statement made under this
section shall be a misdemeanor of third degree.
+++++++++++++++++++++
I, ___________________, do hereby swear or affirm that I am the parent, guardian, or
person having control of _____________________ who is registering as a student in the York
Suburban School District. I further swear or affirm that _____________________ has/has not
(strike out the inappropriate has or has not) ever been suspended or expelled from any public or
private school of this Commonwealth or any other state for an act or offense involving weapons,
alcohol or drugs, or for the willful infliction of injury to another person or for any act of violence
committed on school property.
If the student has been suspended or expelled for any of these offenses, it is your
obligation to provide information relative to the date, the name and location of the school, and the
charges on which the suspension or expulsion was based. This information should be provided
on the reverse of this form or by the way of other official documentation attached to this form.
_____________________________
Witness
___________________________________________
Signature of Parent/Guardian/Person Having Control
_____________________________
Witness
___________________________________________
Street Address
___________________________________________
City, State, Zip
OR
___________________________________________
Phone Number
Notarization:
____________________________
(SEAL)
___________________________________________
Township of Residence
York Suburban School District
Home language Survey
Name: ______________________________________Date:_____________
Date of Birth:_______________________Age:______Grade:____________
Parent/Guardian Name: __________________________________________
Telephone (
) _____________________
1. Is your family and child’s first language English? Check one of the
following: Yes________(If yes, stop survey here)
No ________(If no, please continue with survey)
2. What language does your child speak most often at home?
3. What language(s) do you use when speaking to your child?
4. What language(s) is spoken most often in your home?
5. What language(s) does your child read?________________________
6. What language(s) does your child write? _______________________
7. Does your child understand, but not speak a language other than
English?
Signature of Parent or Guardian: (Required)
York Suburban School District
Student Health History
**To be Completed by Parent**
Student Name: _______________________________Date of Birth ___________ Sex: M
F
Address: _____________________________________Phone ______________ Grade _____
Father: ______________________Mother: ____________________Guardian:____________________
Last School Attended ________________________ City ____________State _______
Please check the illnesses or conditions your child has had. Include dates, if known, and
important details.
Allergies:
Food
_______________________
Insect Bites _______________________
Medications _______________________
Other
_______________________
Asthma
_______________________
Chickenpox _______________________
Diabetes
_______________________
Ear infections _______________________
Emotional problems __________________
Fainting
_______________________
Hearing Problems ___________________
Is your child currently under medical treatment?
Heart Disease ______________________
Hernia
______________________
Head injury
______________________
Orthopedic problems __________________
Pneumonia
______________________
Rheumatic Fever ____________________
Scarlet Fever ________________________
Seizures ___________________________
Skin Condition _______________________
Speech defect _______________________
Urinary tract problem__________________
Vision problems______________________
Yes
No
____________________________
Comments
Please list all medications your child is currently taking. ____________________________________
Please list any operations, serious injuries, illnesses, or other existing physical conditions.
____________________________________________________________________________
Does your child have a doctor? Yes
Birth Information:
No
Is your child covered by insurance? Yes
Birth Weight: __________
Breathing difficulties at birth? Yes
No
No
Were there any abnormal conditions noted at the child’s birth? __________________________
Were there any complications during the mother’s pregnancy, labor, or delivery? ____________
VERIFICATION OF YOUR CHILD’S IMMUNIZATIONS IS REQUIRED. PLEASE ATTACH A COPY
OF YOUR CHILD’S CURRENT IMMUNIZATION RECORD FROM YOUR HEALTH CARE
PROVIDER. THANK YOU!
_____________________________________
Parent/Guardian Signature
________________
Date
YORK SUBURBAN SCHOOL DISTRICT
New Student Parent Inquiry
Date: _____________________
Child’s Name: __________________________________________
Date of Birth:_____________
Address: ________________________________________________________________________
Home phone: _____________
Cell phone: _________________
Child lives with: ___ Both parents ___ Mother ___Father __ Joint Custody Other:__________
Mother’s Name: ____________________________________
Place of Employment: ________________________________Position: _______________________
Father’s Name: _____________________________________
Place of Employment:________________________________ Position: _______________________
Other children in the family:
Age:
Grade:
Sex:
______________________________________
_____
_____
_____
______________________________________
_____
_____
_____
______________________________________
_____
_____
_____
Did your child attend a preschool, Head Start, or day care program?
____Yes
____ No
Program name: ______________________________________
Does your child:
___ wear corrective lenses
___ take any medications
___ have medical concerns/under doctors care
___ receive speech/language services
___ attend LIU preschool
If yes to any of the above, please describe:
__________________________________________________________________________
What holidays does your family celebrate? (This is helpful for classroom planning)
__________________________________________________________________________
MORE ON THE BACK!!
Please describe recent family events or changes (death, divorce/separation, new sibling, moving):
List any special fears and your child’s reaction to those fears (cries, screams, withdrawal, etc.):
Does your child enjoy books?
Do you read to your child?
___ yes
___ yes
___ no
___ no
How often? ________________
What are your child’s strengths?
What are your child’s weaknesses?
What do you expect your child to acquire through the kindergarten experience?
Please mark an X on the continuum to best describe your child in the following areas:
frequently
sometimes
never
Is overly active
1-------------2-------------3-------------4-------------5
Has difficulty separating from Mom/Dad
1-------------2-------------3-------------4-------------5
Becomes upset/cries when plans change
1-------------2-------------3-------------4-------------5
Is shy/timid around others
1-------------2-------------3-------------4-------------5
Has difficulty sharing/taking turns
1-------------2-------------3-------------4-------------5
Has problems getting along with other children
1-------------2-------------3-------------4-------------5
Please use this space to list any other information you would like the teacher to know.
Permission to Release Student Information
PLEASE FORWARD THIS FORM OR A COPY WITH THE STUDENT RECORDS
1. Student’s Name ___________________________________________ Grade _______
Date of Birth ____________________
has enrolled in the York Suburban School District on ________________________.
2. I hereby give permission for __________________________________________________ to release the following information to
(Name of Previous School)
York Suburban School District for the above-named student. It is my understanding that all information will be utilized only by
professional personnel to aid my child in his/her educational program.
_____ Academic Records including current withdrawal grades
_____ Grading system explanation
_____ Attendance Records
_____ Disciplinary Records
_____ Immunization Records
_____ Health and Dental Records
_____ School Violence Report (if applicable)
_____ Psychological/Psychiatric evaluations
_____ Comprehensive Evaluation Report (CER/ER)
_____ Multi-Disciplinary Evaluation (MDE)
_____ Individualized Educational Program (IEP)
_____ NORA/NOREP
_____ PSSA or State Testing results
_____ PA Secure ID
___________________________________________________
_____________________
(Signature of Parent/Guardian)
(Date)
(According to the Final-Regulations-Family Rights and Privacy Act (Buckley Amendment) date June 17, 1976, it is no longer
necessary to obtain written consent to release records between schools.)
The above information is to be sent to:
> Guidance Office
York Suburban High School
1800 Hollywood Drive
York, PA 17403
Attn: Kim Knowles
Phone: 717-845-5415
Fax: 717-843-2702
>
East York Elementary School
701 Erlen Drive
York, PA 17402
Attn: Gayle Rudacille
Phone: 717-755-1021
Fax: 717-840-4185
>
Guidance Office
York Suburban Middle School
455 Sundale Drive
York, PA 17402
Attn: Judy Everett
Phone: 717-840-9214
Fax: 717-757-0613
>
Indian Rock Elementary School
1500 Indian Rock Dam Road
York, PA 17403
Attn: Patty Shaffer
Phone: 717-845-6651
Fax: 717-843-3695
___________________________________________________
(Signature of School Official)
>
Valley View Center
850 Southern Road
York, PA 17403
Attn: Peggy Dunty
Phone: 717-843-0305
Fax: 717-843-3298