checklist - enrollmentfootnotes: 1. these laws are: section 9528 of the elementary and secondary...

Required Information for Student Registration:

[ ] Student's Birth Certificate

[ ] Picture ID of a parent or court-appointed custodian

[ ] Proof of Residence (must provide two (2) forms):

The proof of residence must be in the name of the parent or court-appointed custodian.

Examples:

Driver's license

Most recent utility bill

Signed mortgage, rental, or lease papers

Notarized letter of residence from landlord in lieu of lease

[ ] Immunization Records

[ ] Transcript / Grades (from previous school)

[ ] Student Information Form

[ ] Student Emergency Medical & Health Needs Information Form

[ ] Home (Primary) Language Survey

[ ] Release of Student Directory Information

[ ] Student Residency Questionnaire

[ ] Custody / Living With Form

[ ] Acceptable Use Agreement for Student Access to the Internet

[ ]

[ ] Student Substance Abuse Program Release Form

[ ] Automated Call Permission - Parent/Guardian Form

[ ] Military Form

[ ]

Partial list of additional information may be requested:

[ ] Withdrawal slip from previous school

[ ] Proof of custody

[ ] Discipline records from previous school

CHECKLIST - ENROLLMENT

Entire contents of registration packet must be filled out and returned to your child's school upon completion.

For questions concerning these forms, contact your child's school data manager.

In an effort to assist you with your registration, the following checklist is provided as a reminder of the

documents you will need to register your child(ren) in an Elkin City School.

NC Health Assessment Transmittal Form

(to be completed for ALL new students entering a NC Public School system for the first time)

Transfer Student Declaration

Elkin High - 336-835-3858 Elkin Middle - 336-835-3175 Elkin Elementary - 336-835-2756

Student Name:

Last First Middle

School Attending: [ ] Elkin High [ ] Elkin Middle [ ] Elkin Elementary Grade

Mailing Address: Suite / Apt #

Residential (911) Address: Suite / Apt #

Date of Birth: / / Age: Gender: [ ] M [ ] F

Ethnicity: [ ] Non-Hispanic Race: [ ] American Indian or Alaska Native [ ] Asian [ ] White

[ ] Hispanic/Latino [ ] Native Hawaiian/Other Pac Islander [ ] Black / African American

Student Home Phone: ( ) -

County of Residence: School District Coming From:

Does the student have any of these plans in place? Other

If Other please list

Mother's Name: Father's Name:

Home Phone: ( ) - Home Phone: ( ) -

Cell Phone: ( ) - Cell Phone: ( ) -

E-MAIL: E-MAIL:

Employer: Employer:

Employer Phone: ( ) - Employer Phone: ( ) -

Guardian's Name: Student Lives With: [ ] Mother

Home Phone: ( ) - [ ] Father [ ] Guardian

Cell Phone: ( ) -

E-MAIL:

Employer:

Employer Phone: ( ) -

Emergency Contact Name

#1

#2

#3

#4

#5

In an EMERGENCY situation please list IN ORDER , including parents/guardians, who you would like contacted.

PARENT / GUARDIAN INFORMATION

EMERGENCY CONTACTS

Relationship Lives in Home? Can Pick-Up? Home # Cell #

STUDENT INFORMATION FORM

Student Alerts (Guardian, Medical) :

AIG EC 504 LEP


Student Name:

Last First Middle


[ ] My child does NOT have any medical or health needs in which the school should be aware.

[ ] My child has medical and/or health needs that require a health plan of care.

[ ] None [ ] Bee Sting Reaction:

[ ] Latex [ ] Medication (at school?)

[ ] Peanut Allergy [ ] Asthma Last Episode:

[ ] Other Allergy [ ] Medication (at school?)

[ ] Diabetes [ ] Seizures Last Episode:

[ ] Sickle Cell Disease [ ] Medication (at school?)

[ ] Bleeding Disorder [ ] Orthopedic Condition Type

[ ] Stomach Condition Last Treated?

[ ] Lung Condition (Other than Asthma) [ ] Heart Condition Type

[ ] Nose Bleeds (Frequent) Last Treated?

[ ] Hearing Condition [ ] Kidney Condition Type

[ ] Wears Hearing Device Last Treated?

[ ] Vision Condition [ ] ADHD/ADD

[ ] Wears Glasses / Contacts [ ] Medication (at school?)

[ ] Migraines [ ] Psychiatric Condition

[ ] Medication (at school?) [ ] Medication (at school?)

[ ] Other

Parent Signature Date / /

My child had a head injury/concussion in the past 12 months. [ ] NO [ ] YES Date / /

If YES, please explain

I give permission for my child to participate in mass school health screenings such as vision, hearing, height,

weight, dental, etc., which may be conducted for selected grade levels. [ ] NO [ ] YES

[ ] Health Dept [ ] Hospital Clinic [ ] Health Check/Health Choice[ ] Community Health Ctr [ ] Medicaid [ ] No Insurance[ ] Private Doctor/HMO [ ] Private Insurance/HMO [ ] Other

Doctor Name/Phone [ ] I would like information about freeDentist Name/Phone low cost health insurance for my child.

Parent Signature Date / /

EMERGENCY MEDICAL & HEALTH FORM

HEALTH CARE INFORMATION - Check all that apply

In case of a medical emergency, injury or serious illness, I hereby authorize school personnel to call an ambulance and send

my child to a hospital. I authorize the physician, hospital and/or emergency medical personnel to provide emergency care

in the event that I cannot be contacted immediately.

MASS HEALTH SCREENINGS

EMERGENCY SITUATION


Student Name:

Last First Middle



1. In what city, state and country were you born?

2. When did you first enter a U.S. School?

3. Is the language you first learned or your home language anything other than English? [ ] Y [ ] N

4. What is the first language you (the student) learned to speak?

5. What language is most often spoken in your home?

6. What language do you (the student) speak most often?

7. Besides languages studied in school, do you speak any language other than English? [ ] Y [ ] N

If Yes, please list the language(s)

Signature Date / /

Central Office - Added to NOM list: [ ] Y [ ] N Date of Entry: / /

PowerSchool Data Manager Signature:

HOME PRIMARY LANGUAGE SURVEY

person completing the form

Original copy should be placed in the student's cumulative folder.

Copies should be sent to the ESL Director and the student's ESL teacher.

This form should be completed by the student or parent on behalf of the student.

If the student has a language other than English in his/her background, we will assess their English language

proficiency with the W-APT to determine whether additional assistance with English needs to be provided.

To the administrator: This survey should be administered to every student when he/she

initially enrolls in your school and maintained in the student's permanent record. If the

answer to any of these questions is a language other than English, the student will need to

be reported on the annual Home Language Survey Summary and assessed further for

appropriate placement and English language assistance. Young children may need to have

the survey filled out by a parent or guardian. Additional assistance may be needed from a

translator or interpreter.

For Office

Use Only:


Student Name:

Last First Middle


A playbill, showing your student's role in a drama production The annual yearbook Honor roll or other recognition lists Graduation programs

Student's name Date and place of birth Participation in officially recognized activities and sports

Address Major field of study Weight and height of members of athletic teams

Telephone listing Dates of attendance Degrees, honors, and awards received

E-MAIL Address Grade level Most recent educational agency or institution attended

Photograph

Please complete portion below & return the form to your child's school

[ ] YES

[ ] YES, with Exceptions: I wish to withhold consent and not release information for the following:

[ ] Military Recruitment [ ] College Recruitment

If you do not want Elkin City Schools to disclose directory information, you must notify the district in writing. Elkin City Schools has

designated the following information as directory information:

STUDENT RELEASE FORM

Parent / Guardian SignatureStudent Name (Please Print) Date Completed

Directory information, which is information that is generally not considered harmful or an invasion of privacy if released, can also

be disclosed to outside organizations without a parent's prior written consent. Outside organizations include, but are not limited

to, companies that manufacture class rings or publish yearbooks. In addition, two federal laws require local educational agencies

(LEA's) receiving assistance under the Elementary and Secondary Education Act of 1965 (ESEA) to provide military recruiters, upon

request, with three directory information categories--names, addresses and telephone listings--unless parents have advised the

LEA that they do not want their student's information disclosed without their prior written consent. 1.

Student ID number, user ID, or other unique personal identifier used to communicate in electronic systems that

cannot be used to access education records without a PIN, password, etc. (A student's SSN, in whole or in part,

cannot be used for this purpose).

Footnotes: 1. These laws are: Section 9528 of the Elementary and Secondary Education Act (20 U.S.C.§ 7908), as amended

and 10 U.S.C.§ 503 ©, as amended.

Elkin City Schools has my permission to release any or all of the above directory information

regarding my child in order to meet the requirements of daily school operation.

Sports activity sheets, such as for wrestling, showing weight &

height of team members

The Family Educational Rights and Privacy Act (FERPA), a Federal law, requires that Elkin City Schools, with certain

exceptions, obtain your written consent prior to the disclosure of personally identifiable information from your child's

education records. However, Elkin City Schools may disclose appropriately designated "directory information" without

written consent, unless you have advised the district to the contrary in accordance with district procedures. The primary

purpose of directory information is to allow Elkin City Schools to include this type of information from your child's education

records in certain school publications, such as:


Student Name:

Last First Middle



1. Is your correct address a temporary living arrangement? [ ] YES [ ] NO

2. Is this temporary living arrangement due to loss of housing or economic hardship? [ ] YES [ ] NO

If you answered YES to either of the above questions, please complete the remainder of this form.

If you answered NO to both questions, do not complete the form below.

Which of the situations below apply to the student? (Check any or all that apply)

Student is sharing a residence with one or more families temporarily.

Student is living in a motel or hotel.Student is living in a shelter (domestic violence, emergency, or transitional housing units).Student is living in a car, park, campground, or public place.Student is living in a place without adequate facilities (running water, heat, electricity).Student is seeking enrollment without an accompanying parent (not in foster care).

Please notify the school if your living status changes.

Ethnicity: [ ] Non-Hispanic Race: [ ] American Indian or Alaska Native [ ] Asian [ ] White

[ ] Hispanic/Latino [ ] Native Hawaiian/Other Pac Islander [ ] Black / African American

Name of Parent(s) / Legal Guardian(s)

Address

Home or Primary Phone(s)

Name(s) and age(s) of other children in your home who do NOT attend Elkin City Schools:

Name Age / / Race/Ethnicity [ ] M [ ] F



Parent / Legal Guardian Signature Date / /

School Principal Title I Director Child Nutrition Director

School Guidance Counselor Homeless Liaison

This questionnaire is intended to address the McKinney-Vento Education Assistance Improvement Act 42 U.S.C.

11435. The answers to this questionnaire help determine the services the student is eligible to receive.

STUDENT RESIDENCY QUESTIONNAIRE

If either question is answered "YES", office personnel should send a copy of the completed form ASAP to:

DOB

DOB

DOB

Gender


Student Name:

Last First Middle


Please provide the following information for your student by checking one box in each column below.

Please list any siblings that are currently attending Elkin City Schools & their relationship to the student on this form.

Parent / Legal Guardian Signature Date / /

CUSTODY FORM

[ ] [ ] NO

Living in same HouseholdLegal Custody Print Names Here

[ ]

[ ]

Mother & Father

Mother only

Father only

YES[ ]

YES[ ]

YES

YES

YES

Grandmother only[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

Mother & Stepfather

Father & Stepmother

Grandparents

Grandfather only

[ ] NO

NO

[ ]

[ ]

[ ]

[ ]

[ ]YES[ ]

YES

YES

[ ]

[ ]

[ ]

[ ]

[ ]

NO

NO

NO

NO

NO

(brother, sister, half brother, half sister, stepbrother, stepsister, foster brother, foster sister)

RelationshipName School

NO[ ] Legal Guardian(s) YES[ ]

[ ] YES [ ] NO[ ] Other (Please list)

[ ]

[ ] EES [ ] EMS [ ] EHS

[ ] EES [ ] EMS [ ] EHS

[ ] EES [ ] EMS [ ] EHS

[ ] EES [ ] EMS [ ] EHS


Student Name:

Last First Middle


1.

2. I will use appropriate language and will avoid swearing and using vulgarities.

N3.

4.

5.

6. I will get my teacher's permission and obey copyright laws before I download any data from the Internet.

7.

8.

9. I will utilize the school computer systems only for educational purposes.

10. I will not purposefully commit any unethical activity while using the computer systems.

11.

12.

Parent or Guardian Agreement

ACCEPTABLE USE AGREEMENT

I will submit for administrator approval any text, e-mail, or other information that would be displayed on the web

sites at Elkin City Schools. I understand that any artwork or writing I wish to post on Elkin City Schools' web pages

will appear with a copyright notice prohibiting the copying of such work without forms from parent or guardian.

I agree to abide by the following rules and regulations for computer systems, networks, and Internet access for

Elkin City Schools. I understand that any violation may result in the loss of privileges.

I will behave in a mature, responsible manner when accessing the school computer systems and will obey rules and

procedures in use by Elkin City Schools.

I will not reveal personal information on the Internet, including personal addresses, telephone numbers, credit cards,

checking account information, or Social Security numbers for myself or for anyone else.

I will not attempt to gain unauthorized access to system programs or computer equipment. I will not use anyone

else's password or allow others to use mine. I understand that if I am identified as a security risk for having a history

of problems with computer systems in the schools, I can be denied access to the computer systems by Elkin City

Schools.

I will assume that all communications and information accessible via the network are private property. I will not

make illegal use of data or work files. I will forward personal communications only with the author's prior consent.

I will access only appropriate materials, and will avoid any materials which would generally be considered

objectionable, suggestive, or which charge for services.

Date CompletedParent / Guardian Signature (Print & Signature)

I understand that if I bring any software on campus for installation, I must donate the software and all

documentation to the system administrator.

I understand that filtering software is in place as required by the Children's Internet Protection Act and the

Neighborhood Children's Protection Act may not restrict access to all inappropriate materials and that I will not

attempt to view any inappropriate material.

Student Name (Print) Student Name (Signature) Date Completed

I have read the above rules and regulations for Elkin City Schools' use of computer systems and understand that this access is

designed for educational purposes. I also recognize that filtering software is in place as required by the Children's Internet

Protection Act and the Neighborhood Children's Protection Act may not restrict access to all inappropriate materials. I

accept full responsibility for my child's compliance with the above rules and regulations and hereby give permission for my

child to use the technology available in the Elkin City Schools.

[ ]

[ ]

I give consent for my child to access the Internet at school.

I DO NOT give consent for my child to access the Internet at school.


Student Name:

Last First Middle

School Attending: Elkin High [ ] Elkin Middle [ ] Elkin Elementary Grade

Today's Date: Date of Birth:

Parent(s) / Guardian(s) Full Name(s):

Physical (911 Residential) address where student is living (do not list PO Box):

Home or Primary Phone:

Name and Address of Previous School:

Check the appropriate boxes to answer the following questions:

[ ] YES [ ] NO I have been suspended from my previous school within the past year.

[ ] YES [ ] NO I have been expelled from a previous school, either public or private, during my school career.

[ ] YES [ ] NO I have been convicted of a felony.

[ ] YES [ ] NO I am currently charged with a felony.

TRANSFER STUDENT DECLARATION

Parent / Guardian Signature Date

Legislation from the 1997 North Carolina General Assembly authorizes local schools to secure documentation from students

who transfer into the public schools regarding that student's discipline record at previous schools.

DateStudent Signature

[ ]


Student Name:

Last First Middle

School Attending: Elkin High [ ] Elkin Middle Grade

Date of Birth: / / Student Home Phone: ( ) -

Student Address:

Parent(s) / Guardian(s) Name(s):

Parent(s) / Guardian(s) Phone #'s

[ ]

We the undersigned student and parent understand that if the student refuses to take the random drug test or tests

positive and refuses to participate in the assessment or recommended intervention, then the MRO will inform the school

principal or designee that the student has chosen to drop from the Drug Free Elkin Program. Consequently, according to

school board policy, we understand that the student will have chosen not to participate in extracurricular activities and/or

drive a vehicle on campus for 365 days.

STUDENT SUBSTANCE ABUSE PROGRAM

Student Substance Abuse Program SignaturesEvery student is encouraged to participate. However, it is required for participation in

extracurricular activities and driving vehicles.

Yes, my child will participate

Participant Pledge Card - Permission Release Form

We the undersigned student and parent have read and understand policy 4326: Student Substance Abuse. We give our

consent for the student to participate for his/her entire career while enrolled at this school and understand that

participation includes random selection for urinalysis drug testing. If selected, the student agrees to provide a urine

sample for testing. We also agree to submit appropriate documentation of any medications the student is using to the

program's Medical Review Officer (MRO).

We authorize the MRO to release results of the student's test to his/her parent/guardian and the agency authorized to

conduct the assessment. As parent(s), I/we agree to participate with my/our child in obtaining the appropriate

assistance if she/he tests "positive". The MRO is authorized to release the student's decision about remaining a program

participant to the student's principal (or designee) and to the agency authorized to conduct the assessment. We also

understand that a student/parent may revoke this agreement at any time with the exception of any actions currently in

process, and that we must revoke the agreement in writing.

Student Signature Date

Parent / Guardian Signature Date

No, my child will not participate


Student Name:

Last First Middle


Telephone Consumer Protection Act related to Blackboard Connect

* Phone opt-out options are included at the end of all messages* Touch-tone opt-out is available for live answer deliveries* Opt-out hotline 855-502-7867 is available for answering machine deliveries

* SMS opt-out options are included at the end of all SMS messages

Parent / Guardian Name (printed): Date: / /

Parent / Guardian Signature: Date: / /

Primary Phone Number:

Secondary Phone Number:

E-Mail:

Secondary E-Mail:

Students enrolled in Elkin City Schools:

The Elkin City School system uses an automated dialing system to contact parents/guardians via home phones, cell

phones, and e-mail to inform you of important events, parent conferences, and activities. In order to be included on

the calls, we need your permission. Please fill out this form to indicate whether or not you wish to be included on

informational calls from the Elkin City School system. You will have the option to "opt-out" at any point.

[ ]

AUTOMATED CALL PERMISSION FORM

Checking this box indicates that I DO

NOT wish to receive any calls, texts,

or e-mails from Elkin City Schools

automated system. Emergency calls

may still be received.

Please complete one form PER Parent / Guardian.

Regardless of the number of students enrolled in Elkin City Schools, each Parent / Guardian will only

complete one page .

Emergency calls (such as weather closures/delays and absences) are not affected by federal guidelines, because they

may affect the health and welfare of children who attend our schools.

As a parent or guardian of a student in Elkin City Schools, I give my permission for Elkin City Schools to make non-

emergency calls, texts, or emails using automatic dialing equipment at the phone numbers and e-mails listed below. I

am listing my current numbers on this permission form, but I also permit Elkin City Schools to call or text any numbers I

may provide to the school in the future if my phone number changes. I understand that I may change my mind at any

time and may contact the school or Britt Shaw ([email protected]) to have my numbers removed from the

automated dialing system.


Student Name:

Last First Middle


Even if you selected "NO" above, it is important that you return this form to your child's school no later than September

30th of the current school year.

This mandatory collection was implemented in Elkin City Schools in the 2016-2017 school year. The Session Law 2014-2015

that describes this requirement can be accessed at: http://www.ncleg.net/Sessions/2013/Bills/House/PDF/H1060v3.pdf.

Branch: Air Force, Army, Coast Guard, Marine Corps, Navy, Reserves

Military Grade: Enlisted (E1-E-9), Officer (O1-O10), Warrant Officer (W-1-W5)

Status: Active, National Guard, Reserves, Retired Military, Disabled Veteran, Federal Civil Service, Veteran, Foreign Military,

Active Reserve/Guard, Deceased, Deceased - Killed in Action

Installation: The facility where the service member fulfills their duty / role in the military.

(ex: Fort Bragg, Raleigh, NC, NG Armory, Knightdale Reserve Center)

Unit / Squadron: "Optional"

NOTE: NC General Statute does not mandate that this letter, or any other communication on this data collection, be

mailed through the U.S. Postal Service. Distribution through student folders or other internal communications is sufficient.

If Other is selected above, please list relationship here:

Other

Stepfather

Stepmother

Guardian

Sibling

MILITARY-CONNECTED FORM

Father

Mother

If you answered YES above, please complete the table below.

Complete the "Immediate Military Family Information" below & return to your child's school upon completion.

Same Household? Branch

According to Session Law 2014-15 House Bill 1060: in an effort to ensure the unique needs of military-connected students

are met, the bill requires the NC State Board of Education and NC Department of Public Instruction to collect information

on military-connected students (Military Student Identifier).

The goal is to help accommodate these students by providing them with support and consistency when their family

members are deployed, when they are transitioning between schools, or other pivotal times during their academic career.

Military Grade Status Installation Unit / Squadron

[ ]

Is your student military-connected? YES NO

Relationship


checklist - enrollmentfootnotes: 1. these laws are: section 9528 of the elementary and secondary...

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