LAWRENCE COUNTY SCHOOL ENROLLMENT FORM K-12
Must be Completed by Parent/Legal Guardian
SCHOOL NAME: / SCHOOL YEAR: 2017-18 / TODAY’S DATE:BUS NUMBER: / A.M. BUS DRIVER: / CAR RIDER: Yes No A.M.
BUS NUMBER: / P.M. BUS DRIVER: / CAR RIDER: Yes No P.M.
STUDENT INFORMATION (PLEASE COMPLETE IN BLUE OR BLACK INK)
STUDENT’S LAST NAME / FIRST NAME / MIDDLE NAME / MAIDEN OR NICKNAMEETHNICITY:(Check One): No, not Hispanic/Latino
Yes, Hispanic/Latino(Cuban, Mexican, Puerto Rican, South or Central America or other Spanish culture or origin, regardless of race.)
The above question is about ethnicity, not race. Please mark one of the following boxes to indicate your child’s race.
RACE:(Check One) White Black/African American Pacific Islander/Hawaiian Asian American Indian/Alaska Native
Grade Level
______ / Sex
Male Female / Social Security Number (Voluntary)
______- ______- ______ / Student’s Primary Language
EnglishSpanish Other
Date of Birth
/ / / Birth Country Age Verification Document Presented:
Birth Certificate ____ Hospital Record ____ Physician’s Document ____ Other Specify: ______
Mailing Address Apt. No
City / State / Zip / Home Phone
( ) - ______- ______
Street Address (if different from mailing address)
SCHOOL HISTORY
Check one / I have attended one or more of the Lawrence County Schools beforeI have NOT attended one or more of the Lawrence County Schools before
LastSchool Attended / Phone
( ) - ______- ______
Address / City / State
Previous Grade Level / Date Withdrawn / Student in good standing?
Yes No
FAMILY INFORMATION
Student lives with… Both Parents Mother/Stepfather Mother Only AgencyGuardian Father/Stepmother Father Only Other (specify) ______
Mother/Guardian Name (Circle One) Dr. Mr. Mrs. Miss. Ms. / Cell Phone
( ) - _____ - ______ / Business Phone
( ) - _____ - ______ / Extension
Place of Work: / City Where Works: / Email Address:
Father/Guardian Name (Circle One) Dr. Mr. Mrs. Miss. Ms. / Cell Phone
( ) - _____ - ______ / Business Phone
( ) - _____ - ______ / Extension
Place of Work: / City Where Works: / Email Address:
Please list names of other siblings who attend Lawrence County Schools / School Attending / Grade
1.
2.
3.
EMERGENCY INFORMATION
List at least two local persons (other than yourself) usually available during the day who have agreed to provide transportation and/or assistance for your child if he/she becomes ill or injured and you cannot be reached.Name of Emergency Contact / Relationship to Child / Daytime Phone / Cell Phone
1. / ( ) - _____ - ______ / ( ) - _____ - ______
2. / ( ) - _____ - ______ / ( ) - _____ - ______
3. / ( ) - _____ - ______ / ( ) - _____ - ______
STUDENT NAME: ______SCHOOL: ______(Page 2)
Lawrence County Schools uses an automated calling system to notify parents of emergency closings and special school events. Provide contact numbers for the automated calling system, below. Please notify the school if these numbers change.Primary Numbers (Called First) / ( ) - _____ - ______Ext ____ / ( ) - _____ - ______Ext ____
Secondary Numbers / ( ) - _____ - ______Ext ____ / ( ) - _____ - ______Ext ____
ABSENCE EXCUSES
By law, a parent/guardian/custodian is responsible for sending a written note to school explaining the cause or causes of his/her child’s absence from school. Notes should be sent to school within 3 Days of each absentee.SPECIAL EDUCATION
Has your child received Special Education services within the last year? / Yes NoCheck all that apply: Gifted Title I reading Title I Math ESL Speech SLD ED MR
Other (Specify)
PRE K AND KINDERGARTEN REGISTRATION
Please check the appropriate box if your child has participated in one of the following preschool programs / Please check the best choice of the age your child was when he/she participated in a preschool programHead Start
State Funded Preschool
Center Based Childcare
Home Based Childcare
Home Visitation Program
Even Start
Migrant Program
NO PRESCHOOL
Other (Name) ______ / 3 Year Old Program only
4 Year Old Program only
5 Year Old Program only
3 Year Old & 4 Year Old Program only
4 Year Old and 5 year Old Program only
3 Year Old, 4 Year Old, and 5 Year Old Program only
Other ______
RESIDENCY VERIFICATION
Verification of Residency within school district / Yes NoSource of Document (electric bill, lease or deed, tax assessment etc.)
The residency information provided on this form is true and accurate of this date. I understand that the school system is under a district court order to verify residency. I understand that falsification of an address or the use of any other fraudulent (false) means to achieve enrollment or assignment shall be cause of revocation (removal) of the students’ enrollment and assignment to the school serving the home attendance area.
MILITARY
Student connected to an Active Duty Military Family / Circle One: YES NO
Student connected to a Guard or Reserve Military Family / Circle One: YES…….NO
I certify that the above information is correct. I will notify the school if any of the information on this enrollment form changes.
Signature of Parent/Guardian______Date______
It shall be the policy of the Lawrence County Board of Education to provide educational opportunities for children on a non discriminatory basis. No person shall be denied the benefits of any education program or activity on the basis of race, color, disability, creed, national origin, or sex. All programs offered by the Lawrence County School system shall be open to all students in compliance with statutory and judicial requirements. The enrollment of homeless, migrant, and limited English proficient children shall not be denied due to any barriers.
*Disclosure of your child’s social security number (SSN) is voluntary. If you elect not to provide a SSN, a temporary identification number will be generated and utilized instead. Your child’s SSN is being requested for use in conjunction with enrollment in school as provided in Ala. Admin. Code §290-3-1-02(2)(b)(2). It will be used as a means of identification in the statewide student management system.
Verification of Residency
The United States District Court, Northern Division, Judge David Proctor, presiding, in Horton v. Lawrence County Board of Education, 5:66-CV-0445-RDP approved a Joint Report requiring that all students who attend public school in the Lawrence County School System attend in the school attendance zone as determined by their residence. Further, the Lawrence County Board of Education is required to verify the residency of all High School Students currently enrolled in the school system, as well as, all students who enroll in the future.
The parents/guardians of each student must submit the following information under oath. Please note that this sworn statement may be filed with the U.S. District Court, Northern Division; therefore, all information must be accurate and truthful.
Student’s Name______School ______
Parent’s/Guardian’s Name ______Phone ______
Home Address ______City______Zip code ______
(Home addressmust be the student’s primary residence)
Under oath, I swear or affirm that the child, whose name appears on this form, lives at the address noted above. In support of my sworn statement, I am attaching here to the following documents:
- A copy of the deed to my property or a copy of my lease;
- A copy of the tax Assessment from the Lawrence County Revenue Commissioner’s Office;
- A copy of the Electric Bill showing the account in my name and the address of the property.
(The following section is to be completed by a Notary Public. If you cannot secure the services of a notary, one will be available at the school office.)
Signed this ______day of ______, 20______
______(Signature)
Sworn before me this ______day of ______, 20______
______Seal Here
Notary Public My Commission Expires ______
In the event that the above information is not supplied, the school system will suspend the student, until the parent/guardian meets with the Student Mobility Committee.
*If the parent / guardian is not named on the lease / deed, then the owner of the property must sign a written statement that identifies the person(s) residing on the property listed above.