Berryhill StudentEnrollment Form

Please indicate the student’s academic placement. Choose OneNew KindergartenerNew Pre-KindergartenNew student entering 1st gradeNew student entering 2nd gradeNew student entering 3rd gradeNew student entering 4th gradeNew student entering 5th gradeNew student entering 6th gradeNew student entering 7th gradeNew Student entering 8th grade
Child’s Information
Birth certificate or other satisfactory evidence of age and official record of immunizations must be presented at the time of enrollment. Copies of these documents are placed in folder and originals returned to parent/guardian.
Child’s Last Name / Child’s First Name
Address / Grade
Home Phone # / Birth Date
Family Information
Student lives with / Choose MotherFatherGuardian(s)Mother and FatherFather and StepmotherMother and Stepfather
Father/Male Guardian Information / Mother/Female GuardianInformation
Name / Name
Home Phone # / Home Phone #
Cell Phone # / Cell Phone #
Employer / Employer
Work Phone # / Work Phone #
Email / Email
Highest education level completed / Highest education level completed
Siblings Who Attend Berryhill School
Name / Grade / ChoosePre-KK1st2nd3rd4th5th6th7th8th
Name / Grade / ChoosePre-KK1st2nd3rd4th5th6th7th8th
Name / Grade / ChoosePre-KK1st2nd3rd4th5th6th7th8th
Name / Grade / ChoosePre-KK1st2nd3rd4th5th6th7th8th
Morning and Afternoon Transportation
Morning –Provide requested information / Afternoon – Provide requested information
ChooseBus RiderCar RiderOther / ChooseBus RiderCar RiderOther
If you chose other, describe how your child gets to school. / If you chose other, describe how your child gets to school.
Individuals with Permission to Pick your Child Up From School
In case of an emergency/early dismissal/ inclimate weather/ carpool/ after school clubs. Please list all people, as we cannot release your child to anyone who is not on this list. If your child has an accident or becomes ill and you cannot be reached, one of the individuals listed below will be called.
Any individual who you list below will be asked to show identification in order to pick your child up at Berryhill.
Name / Relation to Family / Home Phone # / Cell Phone #
Name / Relation to Family / Home Phone # / Cell Phone #
Name / Relation to Family / Home Phone # / Cell Phone #
Name / Relation to Family / Home Phone # / Cell Phone #
Previous School Information (if Applicable)
Please indicate the student’s previous academic placement (if applicable)Choose OnePrivate school in Mecklenburg CountyCharter school in Mecklenburg CountyGroup Home or other institutionPrivate school outside Mecklenburg CountyCharter school outside Mecklenburg CountyPublic School outside Mecklenburg CountyHome School Setting
Date your child first attended K-12 school in United States
Last School Attended: / Grade: Choose OnePre-KK1st2nd3rd4th5th6th7th8th
Address:
Date Last Attended: / Homeroom Teacher:
Has the student ever been enrolled in CMS?
Yes No / If yes, School Name: School Year:
Is the student identified as a student with special needs and being served with an Individualized Education Plan (IEP)? Yes No
Home Language Survey
Please answer the following questions.
  1. What language did your child speak when he or she first began to talk?
  2. What language does your child speak most often at home with parents?
  3. What language does your child speak most often with his or her friends?
  4. What language do YOU use most often when speaking to your child?
  5. What language do YOU prefer school communications sent in? ChooseEnglishSpanishOther
If you chose other, what language do you prefer?
Any students that indicates a language other than English, must be administered the English language proficiency test to meet federal NCLB Title III regulations.
Child’s Medical Information
For your child’s safety, medical information will be shared with appropriate school staff. This will be handled on a need to know basis. Does your child have any of the following conditions? Please check all that apply:
Allergies / Asthma / Other Medical Concerns/Conditions
Food Allergies
List Foods:
Insect Allergies
Uses an Epi-Pen for allergic reactions
Other Allergies/Additional Information: / Daily Asthma Medication
Uses Inhaler at School
Uses Inhaler at home / ADHD/ADD / Sickle Cell Disease / Cerebral Palsy
Bone Issues / High Blood Pressure / Hearing Loss
Muscle Issues / Low Blood Pressure / Heart Trouble
Epilepsy / Bladder/Urinary Issue / Vision Issues
Hemophilia / Utilizes a Wheelchair / Bowel Issues
Headaches / Utilizes a walker / Hypoglycemia
Diabetes / Obsessive Compulsive / Depression
Below, please list your child’s medications. In an emergency, medical providers need the information to effectively treat your child.
Medication: / Medication: / Medication:
Below, please indicate any other health concerns or explanations for any of the above listed concerns/conditions:
Doctor’s Name: / Dentist’s Name:
Doctor’s #: / Dentist’s #:
Permission to obtain medical attention Yes No
Permission for school/nurse to share my child’s shot records with the North Carolina Immunization Registry and/or a provider who needs it when giving my child immunizations. Yes No
Medications at School: Medication Authorization Form must be completed by the doctor for medications to be given at school.
Your signature below indicates that if your child needs immediate medical attention and you cannot be reached, the principal/designee has permission to send your child to the emergency room by EMS and that you understand you will be financially responsible for transportation and treatment.
Parent/Guardian Signature / Date
For office use only:
Student ID: / Enrollment Date: Grade:
Teacher’s name: / Need: Immunization Record Birth Cert POR