GREATER JOHNSTOWN SCHOOL DISTRICT

STUDENT REGISTRATION FORM

Student Biographical Information
Student Name______Birthdate_____/_____/______Age_____
(Last) (First) (Middle) (mm) (dd) (yyyy)
Gender M F Grade Entering______Proof of Age Documentation attached Y N
Name of Last School Attended ______
Address of Last School Attended ______Last School’s Phone # ______
______Last School’s Fax # ______
(City) (State) (Zip Code)
Has student ever attended school in PA? Y N Has student ever attended in this school district? Y N
Did student ever attend school outside of the United States? Y N If yes, what country and name of school? ______
What year did student first attend a school in the United States? ______
For state and federal reporting requirements, use the following (select one primary ethnicity and select all race codes that apply):
Select Primary Ethnicity Hispanic/Latino (If Hispanic and another race, please check additional race code below)
(any race)
Race Code(s): American Indian or Alaskan Native; Asian (includes the subcontinent of India Black or African American;
Native Hawaiian or Other Pacific Islander; White
Building:
East Side Elementary West Side Elementary Johnstown Middle School Johnstown Senior High School – If entering HS; has student ever repeated
a grade, if yes, what grade _____and what school year did student enter the 9th grade? ______
Johnstown Cyber School Moxham Neighborhood School Morrell Neighborhood School
Student Miscellaneous Information
Student’s Native Language ______Student’s Country of Birth ______
Is there a Court Order involving this student? ___Y ___N If YES, please provide a copy to the school office, otherwise we are
unable to abide by its contents.
Is there a Custody Order involving this student? ___Y ___N If YES, please provide a copy to the school office, also list the date and
duration or the custody order ______
Is this student adopted? ___Y ___N Is this student a foster child? ___Y ___N Please provide any documentation related to adoption and/or foster placements to the school office and Central Registration
FOR OFFICE USE ONLY
Student ID# ______Date Entered/Reentered ______
Proofs of Residency attached:
(List A)
Lease Mortgage Deed School property tax bill Other ______
(List B)
PA DL/ID card PA auto registration Income Tax Check Stub Local EIT Residency
Institutionalized Child (1306) Y N (If yes, complete PDE-4605 and submit to child accounting)
Foster Child (1305) Y N (If yes, attach 1305 – Affidavit)
Building Enrolled In ______Building Tracking Attendance ______Data Entry/Registrar’s Initials ______
Administrator’s Signature ______Date ______
Primary Address - and First Adult Resident with whom student resides
Name ______Mr./Mrs./Ms.
( Last ) ( First ) ( Middle) (circle one)
Relationship to Child ______
Birthdate______/______/______
Primary Phone Number’s:
Home______-______-______Work ______-______-______Ext ______; Cell ______-______-______
E-Mail Address ______
FIRST ADDRESS (Primary Residence – This Address should be listed as First Address in Student Information System)
Street______
City ______State______Zip Code ______
Secondary Address – and second Adult Resident with whom student resides
Name ______Mr./Mrs./Ms.
( Last ) ( First ) ( Middle) (circle one)
Relationship to Child ______
Birthdate______/______/______
Primary Phone Number’s:
Work ______-______-______Ext ______Cell ______-______-______
E-Mail Address ______
SECOND ADDRESS (Primary Residence – This Address should be listed as SECOND Address in Student Information System)
Street______
City ______State______Zip Code ______
Students Placed At Houston House / Christian Home / or other Shelter
If Student is court-placed or placed in a facility by other means, please indicate the Parent / Guardian Address and District of Residence
Parent / Guardian ______
Street______
City______State______Zip Code ______
District of Residence ______
Student is placed at Houston House ______Christian Home ______Other Shelter, please name ______
ADDITIONAL INFORMATION:
Other children living at this address:
1.) Full Name ______Birthdate ____/____/_____Grade _____School ______
2.) Full Name ______Birthdate ____/____/_____Grade _____School ______
3.) Full Name ______Birthdate ____/____/_____Grade _____School ______
4.) Full Name ______Birthdate ____/____/_____Grade _____School ______
5.) Full Name ______Birthdate ____/____/_____Grade _____ School______
6.) Full Name ______Birthdate ____/____/_____Grade _____ School______
7.) Full Name ______Birthdate ____/____/_____Grade _____ School______
Alternate Parent Information (Parent student does NOT reside with but has educational rights)
Name ______Mr./Mrs./Ms./Dr.
( Last ) ( First ) ( Middle) (circle one)
Relationship to Child ______
Is this parent to receive notices? Y N
Mailing Address: ______
______
Primary Phone Numbers:
Home______-______-______Work ______-______-______Ext ______Cell ______-______-______
E-Mail Address ______
Student Program Information
Check ALL services that your child is currently receiving:
Individualized Education Plan
(Special Education Services) / Gifted Individualized Education Plan
(Gifted Education Services)
Section 504/Chapter 15 Service Agreement
(Special Accommodations for Health/Physical needs) / Early Intervention Program
Preschool Program / Speech/Language Support
ESL (English as a Second Language) / IST (Instructional Support Team)
Remedial Math (Extra Help) / Remedial Reading (Extra Help)

PARENTAL REGISTRATION SWORN STATEMENT

Pennsylvania School Code § 13-1304-A states in part “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 or is presently 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.”

Please complete the following:

I hereby swear or affirm that my child was/was not (check one) previously suspended or expelled, or is/is not (check one) presently 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. I make this statement subject to the penalties of 24 P.S. § 13-1304-A (b) and 18 Pa. C.S.A. § 4904, relating to unsworn falsification to authorities, and the facts contained herein are true and correct to the best of my knowledge, information and belief.

If this student has been or is presently suspended or expelled from another school, please complete the following:
Ø  Name of the school from which student was suspended or expelled - ______
Ø  Dates of suspension or expulsion ______
Ø  Reason for suspension/expulsion (optional) ______
(Please provide additional schools and dates of expulsion or suspension on the back of this sheet.)

I ASSERT THAT THE FACTS SET FORTH HEREIN ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE, INFORMATION AND BELIEF. I UNDERSTAND THAT IT IS A MISDEMEANOR OFFENSE TO KNOWINGLY PROVIDE FALSE INFORMATION IN THIS SWORN STATEMENT FOR THE PURPOSE OF ENROLLING A CHILD IN THE DISTRICT’S SCHOOLS, AND ARE SUBJECT TO THE PENALTIES OF 18 PA. C.S.A. SECTION 4904, RELATING TO UNSWORN FALSIFICATION TO AUTHORITIES.

I further certify that I will notify the Greater Johnstown School District immediately in the event that the facts set for herein shall no longer be correct or shall change. I also certify that I will cooperate with and be responsive to request for information or investigation concerning the continuing validity of this sworn statement.

I, the resident, have read and understand the contents of this document and have received a copy for my keeping. I have received a copy of the Pennsylvania school immunization requirements and required documents for application for registration for school attendance in Pennsylvania. I understand that my child will not be officially enrolled in the Greater Johnstown School District until all completed required documents have been approved by the school authorities. Through my signature, I grant the school district permission to investigate the above information that I have presented in this sworn statement for confirmation and factual accuracy.

______

Parent / Guardian Signature Date

______

Witness