Swartz Creek Community Schools

STUDENT ENROLLMENT/REGISTRATION

 

Name _______________________________________________________________________________________

                                          Last                                                              First                                                              Middle

 

Present Address  ______________________________________________________________________________________

Street/PO Box                                                                                City                            Zip                                  Home Phone

Current Grade  _________      Age  __________      Birthdate_______________       Male _______  Female _______

Birth City/State _____________________________________________S.S.#______________________________ 

Mother’s Home Phone # _______________    Work Phone # _______________        Cell #_______________

Father’s Home Phone # ________________    Work Phone # _______________        Cell #_______________

Stepparent Work Phone #_______________    Work Phone # _______________        Cell #_______________

Is child considered Multi-Racial? Yes _____No _____ If so please list in priority order 1__ 2__ 3__ 4__ 5__ 6__

Race (please circle)     American Indian/Alaskan Native (1)   Asian or Oriental (2)       Hispanic (3)

Hawaiian or Pacific Islander (4)    Black (not of Hispanic origin) (5)     White (not of Hispanic origin) (6)

 

School Last Attended  __________________________________________________________________________________

                                                      Building                                                                    District                                                         City

 

                                        __________________________________________________________________________________

                                                                   State                                                                                                             County

 

Health Problems or Concerns  ___________________________________________________________________________

Father’s Name  _______________________________________________     Birthplace  _____________________

            Step Father’s Name  ________________________________________

Mother’s Name  _____________________________________________        Birthplace  _____________________

            Step Mother’s Name  _______________________________________

Ward of Court  _______________________________________     Guardian  ______________________________

                Affidavit Notarized  ________________________________________

With whom does child reside?____________________________________________________________________

Parent/Guardian Code _____ (See back of form for code and explanation)

___ I am a Resident of the Swartz Creek School District

___ I am Not a Resident of the Swartz Creek School District, but I am a pregnant or parenting teen.

___ Not a Resident of Swartz Creek Schools but I have dropped out of the high school in my District of Residence.

___ Not a Resident of Swartz Creek Schools but I am being referred by the Court.

___ Not a Resident of Swartz Creek Schools, but I have been suspended or expelled from my District of Residence.

Has your child ever been expelled from school?  Yes _____       No _____

Was your child in any special education classes in previous school? Yes _____    No _____

 

Student(s) will Not Be Eligible to Attend School Until All Completed Immunization Records Are Received
 

 

Signature of Parent:________________________________________________________ Date:________________

Parent/Guardian Codes

Parent/Guardian

Code

Father & Mother

1

Father Only

2

Mother Only

3

Father & Stepmother

4

Mother & Stepfather

5

Legal Guardian(s)

6

Foster Parent(s)

7

Grandparent(s)

8

Other Relative

9

Self

10

Other

11

 

Definition of Racial/Ethnic Categories

American Indian or Alaskan Native – A person having origins in any of the original peoples of North America or who maintains cultural identification through tribal affiliation or community recognition.

Asian or Oriental- A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent.  This area includes, e.g.: China, India, Japan, Korea and Samoa.

Hawaiian or Pacific Islander – A person having origins in any of the Pacific Islands or Hawaii.

Hispanic – A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture origin-regardless of race.

Black (Not of Hispanic Origin)- A person having origin in any of the Black racial groups of Africa.

White – A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.

Address Confirmation

 

I, ________________________________________________________________, state that I reside at

 

 

                        Street                                                   City                              State                Zip

 

And am the custodial mother, father, or legal guardian (circle one) ______________________________

                                                                                                                        Child’s Name

 

I understand that falsification of an address for purposes of securing an education for the above named child will result in immediate removal from the Swartz Creek Community Schools.

 

_______________________________________________                          ________________________

                        Signature of Parent/Guardian                                                                             Date