4TH-6TH GRADE REGISTRATION FORMS

(RESIDENT)

Please provide the following items at the time of registration:

FORMS

PROOF OF RESIDENCY (Current Bill- gas/water/electric, or current lease agreement). TYPE:

BIRTH CERTIFICATE

SOCIAL SECURITY CARD

PHOTO ID OR PARENT/GUARDIAN

CURRENT GA IMMUNIZATION FORM

EYE, EAR, DENTAL SCREENING

JOINT CUSTODY SOLE CUSTODY ORIGINAL PARENTS SINGLE CUSTODY

SCHOOL RECORDS FROM PREVIOUS SCHOOL (If student does not have records, parents will complete a

“records request” form)

PREVIOUS SCHOOL:

SCHOOL PHONE #:

CONTACT SPOKEN TO:

STUDENTS INTEREST AND HOBBIES:

STUDENT RECEIVED TOUR OF SCHOOL: YES NO

STUDENT/STAFF WHO CONDUCTED TOUR:

NOTES (FOR OFFICE USE ONLY):

ENROLLMENT CHECKLIST

Date:

STUDENT INFORMATION:

Last Name: First Name: Middle Name:

Preferred Name: Grade: DOB:

(Below must be address of child’s legal guardian) Gender: Male Female

Street Address/Apt #: City/State/Zip:

Mailing Address (if different from above):

Student Social Security #: City Resident: Yes No

Ethnicity: Caucasian Hispanic American Indian African American Asian Multi-Racial

Child lives with: Mother & Father Mother Only Father Only Foster Care

Grandparents Stepmother Stepfather Guardian

Name if other than parent:

Last school attended & reason for leaving:

Student Email:

Student Cell:

Parent Name:

Parent Address:

Parent Employer:

Home Phone: Cell Phone: Work Phone:

Email:

Parent Name:

Parent Address:

Parent Employer:

Home Phone: Cell Phone: Work Phone:

Email: PLEASE COMPLETE IF APPROPRIATE (ATTACH CERTIFIED PROOF OF GUARDIANSHIP):

Guardian’s Name:

Guardian’s Address:

Guardian’s Employer:

Home Phone: Cell Phone: Work Phone:

Email:

If divorced or separated, please indicate which parent has custody (please attached certified copy of custody order): EMERGENCY CONTACTS:

Name: Phone: Relationship:

Name: Phone: Relationship:

Active Military: Yes No Active Reserve: Yes No

Did your child attend a 4 year old program? Yes No If yes, where?

Resident Enrollment Form

PLEASE LIST SIBLINGS WHO ATTEND CARROLLTON CITY SCHOOLS:

Name: Grade:

Name: Grade:

Name: Grade:

Name: Grade:

Please list who may check your child out of school:

Please list who may not check your child out of school:

PARENT/GUARDIAN SIGNATURE DATE

Date: School/Agency RELEASING information: School/Agency RECEIVING Information: School Name:

Address:

Phone:

Contact:

STUDENT INFORMATION: Name: Grade: DOB: SS#: Street Address/ Apt #: City/State/Zip: Parent/Guardian: Phone #: School Leaving: School Entering:

I hereby authorize Carrollton Middle School to OBTAIN pertinent information concerning the above-named student.

I hereby authorize Carrollton Middle School to RELEASE pertinent information concerning the above-named student.

TYPE OF MATERIAL:

I have examined the records indicated above and agree to have them released to the designated agency.

SIGNATURE OF PARENT/GUARDIAN/STUDENT DATE In compliance with the Family Educational Rights and Privacy Act of 1974, these records will be released to

Parents/Guardians or Students over 18 years of age upon their request. The granting of consent is voluntary on the party

of the parent.

RELEASED BY: DATE: It is not necessary for parents to sign a release when records are being passed from public school to public school. Note

Federal Register, Thursday, June 17, 1976, Part II HEW-Private Right of Parents and Student. Final (Vol.41, #118-

24673).

Carrollton Middle School 151 Tom Reeve Dr. Carrollton, GA 30117 Attn: Records Fax: 770-834-5391 Phone: 770-830-0997 Email: shilah.prothro@ carrolltoncityschools.net

REASON FOR REQUEST: ____Educational Planning ____Medical Treatment ____Other_________________________________________________________

CARROLLTON MIDDLE SCHOOL

RECORDS REQUEST ** DO NOT WITHDRAW**

____Standard Educational Record ____Psychological Report ____Educational Evaluation Reports ____Individual Educational Plan ____Special Education Placement Forms ____Vision/Hearing Tests ____Other___________________________________

____Copy of Birth Certificate ____Immunization Records (Form 3231 and 3300) ____Discipline/Attendance ____Individual Educational Plan ____Program/Services (Gifted, ESOL, SST) ____Testing Labels

This form will give Carrollton City Schools permission to transport your child. To enable your child to ride the bus to and from school, this form must be completed and returned to your child’s school as soon as

possible. Please complete one form for each child. (Office use only) Student’s ID#:

(Office use only) Date Code: (PleasePrint)Student’sFullName: (Last) (First) (Middle) Grade: Gender: SocialSecurityNumber:HomeStreetAddress: (Number) (StreetName) (Zip) (Apt#)

Doyourequestmorningbuspick-up? Yes NoMorningbusstoplocationifdifferentfromhomeaddress:

(Number) (StreetName) (Zip) (Apt#)

Doyourequestafternoonbusdrop-off? Yes NoAfternoonbusstoplocationifdifferentfromhomeaddress:(Number) (StreetName) (Zip) (Apt#)

Thesearepick-upanddeliveryaddressesthatyourchildwilluseunlesswrittenchangesaresenttotheschoolandsignedbytheparent/guardian.Theparent/guardianisresponsibleforhavingthechildattheappropriatebusstopinthemorningandforbeingthereontimeintheafternoontoreceivethechild.Igivepermissionfortheabove-namedchildtobetransportedbyCarrolltonCitySchools.Parent/Guardianname(print): Signature: Date:HomePhone#: EmergencyPhone#:

BUS TRANSPORTATION FORM

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Richard Woods, Georgia’s School Superintendent “Educating Georgia’s Future”

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1854 Twin Towers East • 205 Jesse Hill Jr. Drive • Atlanta, Georgia 30334 • www.gadoe.org An Equal Opportunity Employer

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HealthAssessmentRecordSchoolYear:_____-_____

ToParentorGuardian:

Thepurposeofthisformistoprovidetheschoolnursewithadditionalinformationregardingyourchild’shealthneeds.Theschoolnursemaycontactyouforfurtherinformation.Theinformationisessentialfortheschoolnursetomeetthehealthneedsofyourchild.

Thisinformationwillbekeptconfidential.

PARTI:STUDENTINFORMATION

Tobecompletedbytheparent/guardian:

StudentName: School: Grade:

Teacher/Teachers:

NameofParent/Guardian:

Pleaselistphonenumberswhereschoolpersonnelcancontactyouorafamilymemberimmediately:

Name Phone

Name Phone

Name Phone

PleaselistsiblingswhoattendCarrolltonCitySchools:

Name: School:

Name: School:

Name: School:

PARTII:MEDICALHISTORY

Allprescriptionmedicationsandproceduresrequirephysicianorders.

(over)

o NOKNOWNMEDICALPROBLEMSORCONCERNS(Ifno,pleasegodirectlytothebottomofthenextpageandprovideparent/guardiansignature.)

Pleaseprovideallnecessaryinformationthatmayassistincaringforyourchildwhileatschool.

o Allergies:Pleasespecifyallergenanddescribesymptomsofreactiono Food:(Doctor’snoterequiredtobeonfileinthecafeteriatomakefoodsubstitutions)

o Insects:o Environmental:o Medications:

Treatment/medicationtobegivenforanallergicreaction:

o Asthma:Triggers?o He/Sheusesaninhaleratschool.Medication:o He/Sheusesaninhalerathome.Medication:

o Diabetes:(Requiresmedicationandprocedureordersfromphysician)o Type1Diabetico Type2Diabetic

o ADHD/ADDo Requiresmedication?o Tobegivenatschool?

o BleedingProblems:(suchasHemophilia,VonWillebrand’s,frequentnosebleeds)o Pleaseexplain:o Medication?:

o Cancer:o Pleaseexplain:

o CysticFibrosis:o Pleaseexplain:

o HeartCondition:Pleaseexplainifthereareanyactivityrestrictionsorprecautions.Medications?

o JuvenileArthritis/BoneorJointProblems:Pleaseexplainanyactivityrestrictionsorlimitations.

o Seizures:Describetypeofseizuresandlistanymedicationsorderedforthiscondition.

o SickleCellAnemia:Pleaseprovidecommonsymptomsandneedsforyourchild.

o OtherMedicalConcerns:Pleaselistanymedicationstakenathome

MedicalEquipmentandProceduresRequiredatSchool:Pleasecheckifrequired

Catheter GastricTubeFeedings NebulizerTreatments OxygenSupplement Tracheostomy

VagalNerveStimulator(VNS) Ventilator Wheelchair Walker

Parent/GuardianSignature: Date:

SchoolNurseSignature: Date:

HOMELANGUAGESURVEY

Student Name: Date: School: Grade: Dear Parent/Guardian: In order to provide your child with the best possible education, we need to determine how well he or she speaks and understands English. This survey assists school personnel in deciding whether your child may be a candidate for additional English language support. Final qualification for language support is based on the results of an English language assessment. Thank you! Which language does your child most frequently speak at home? Which language do adults in your home most frequently use when speaking to your child? Which language(s) does your child currently understand or speak? If possible, would you prefer notice of school activities in a language other than English?

Yes No If yes, which language? Signature of Parent or Guardian Date

LANGUAGEMINORITYSTUDENTEDUCATIONALPROFILE

Student’s Full Name: DOB: Gender: M F Born in U.S. Yes No OR Date of Entry into U.S.: / / FirstLanguage: DateFirstEnrolledinU.S.School: / / DateEnteredCarrolltonCitySchools: / / EDUCATIONALBACKGROUND

Didstudentattendschoolinanothercountry? Yes NoIfyes,howmanyyears?

InEnglish,canthestudent:Speak Yes NoRead Yes NoWrite Yes No

Inthefirstlanguage,canthestudent:Speak Yes NoRead Yes NoWrite Yes No

DidstudentstudyEnglishbeforecomingtotheU.S.? Yes NoIfyes,howmanyyears?

WasthestudentinanESOLorbilingualprogramintheU.S.? Yes NoIfyes,givelocation:

Lengthoftimeinprogram:

Hasthestudentrepeatedanygrade? Yes No

Ifyes,checkthegrade(s)thatwererepeated:K 1 2 3 4 5 6 7 8 9 10 11 12

Name of School: Carrollton Middle School Name of Student: Grade: Gender: F (Last) (First) (Middle) M Birth Date: Age: Social Security #: (Month/Day/Year) (Or student ID number) This questionnaire is intended to address the McKinney-Vento Act 42 U.S.C 11435. The answers to this residency questionnaire will help determine the services the student may be eligible to receive.

Is your current address a temporary living arrangement? Yes No If yes, is this temporary living arrangement due to loss of housing or economic hardship?

Yes No

If you answered yes to both of the above questions, please complete the remainder of this form. If you answered no, you may stop here.

Where is the student presently living? (check one answer)

In a motel In a shelter With more than one family in a house or apartment Moving from place to place In a place not designed for ordinary sleeping accommodations such as a car, park or

campsite Name of Parent(s)/ Legal Guardian(s): Address: Zip: Phone: Presenting a false record or falsifying records is an offense under Section 37.10, Penal code, and enrollment of the child under false documents subjects the person to liability for tuition or other costs TEC Sec. 25.00(3)(d). Signature of Legal Parent/Guardian Date I certify that the above named student qualifies for the Child Nutrition Program under the provision of the McKinney-Vento Act. Date McKinney-Vento Liaison Signature Office Use Only: Please send a copy to: Homeless Liaison in Student Services Fax#: 770-834-4215

STUDENTRESIDENCYQUESTIONNAIRE

ADDITIONALSERVICESINFORMATION

Student Name: Date: School: Grade: Has your child ever attended Carrollton City Schools? Yes No If yes, list school attended: If your child receives any of the services listed below, please mark all that apply:

Student Support Team (SST) English Language Learner (ELL) Early Intervention Program (EIP) Special Education Gifted Speech 504

Does your child have any medical concerns that we need to be aware of? Yes No If yes, please explain: Will your child require medication during school hours? Yes No If yes, please explain: Parent/Guardian (Printed) Date Parent or Guardian (Signature) Date