Effingham County Board of Education Central Registration

306 North Ash Street, Springfield, GA 31329 Phone: (912) 754-2530

www.effinghamschools.com/crc

Student Name: ________________________________________________

Please read and initial the following:

_____ I am authorized to enroll this student, and understand that in compliance with OCGA 20-2-780 that having enrolled the student, I am the only person who can withdraw the student, unless a court order applies.

_____ The address listed on this form is the physical location where the student actually resides.

_____ I have provided the student’s Georgia Certificate of Immunization (Form 3231) ~OR~ agree to provide Form 3231 within the time specified on the Notification of Wavier form.

_____ I understand that this student’s enrollment is contingent, pending receipt of all disciplinary records from any prior schools attended.

_____ I agree upon request by the school to present such additional proof of residency (such as electric bill, city water, etc.) as shall be reasonably required. I acknowledge that the Effingham County Board of Education in its operation of the Effingham County School System has a legitimate interest in protecting and preserving the quality of the system and the rights of bona fide residents to attend public schools on a preferred tuition-free basis. I also acknowledge that the Board will rely upon this certificate in determining if the student is a bona-fide resident of Effingham County. I also acknowledge that if the proof of residency furnished the Board or as contained in this certificate is not correct, the student will be subject to dismissal and I will be responsible for reimbursing the Board for all local education expenses for the student up to the time of dismissal.

_____ I understand that if this student is being provisionally enrolled without all required documentation, this student is being provided educational services based solely on the information I provide. I understand that changes may be made to the services being provided once records are received from previous schools and have been reviewed by appropriate school personnel. This may include, but is not limited to, grade placement, class placement, teacher assigned, type of instructional setting, and any other changes that the school administration deems necessary.

_____ In case of an accident or serious illness, I give permission for the school to make whatever emergency arrangements are necessary.

_____ As part of the online registration process, I have read and completed the Home Language Survey for this student as provided by the State of Georgia.

I hereby certify that all the information contained in this form is true and accurate to the best of my knowledge.

Signature: __________________________________ Printed Name: ____________________________________ Date: ___________

Central Registration Center Updated: July 2019

Effingham County Schools Request for Records/Transcripts

www.effinghamschools.com

TO: Records/Transcripts FROM: Effingham County Central Registration Center PHONE: DATE: FAX: PHONE: (912) 754-2530

The student named below has entered our school district:

Name: ________________________________________ Date of Birth: ______________ Grade:________ Student’s Previous Address: ___________________________________________________________________________ Previous School Attended: ____________________________________________________________________________ School District: _____________________________________________ City, State: ______________________________

*If student was enrolled in a Georgia Kindergarten program, in addition to providing requested records, please also have classroom teacher release students on GKIDS.

Please fax or mail the following records for enrollment. Please do not send originals.

NOTE: According to Georgia DOE Board Rule 160-5-1-.14, schools must mail or otherwise deliver requested records within 10 calendar days of receipt of request. Schools shall not withhold any student record because of nonpayment of fees.

Withdrawal Form Attendance (Georgia Law) Immunization Certificate EED (Georgia Law) Birth Certificate Current Transcript Gifted Records EIP/Title/Remedial Records ESOL Records

Home Language Survey Social Security Card Discipline Records w/notes Speech Records Accelerated Reader records Transfer Grades Summer school grades 504 (active or inactive) Star Test Summary

Standardized/State Test Scores Student Support Team (active or inactive) Psychological Reports (not special ed) Report Cards from previous school terms Georgia Schools: Career Related Assessments / Inventories / Graduation Plan documentation required by CCRPI and/or BRIDGE law. All other records

Special Education Records (IEP/Eligibility/Psychological Evaluation or Reports) Documentation related to commission of any felony offenses Date of First Time Entry Into Ninth Grade (for graduation cohort determination purposes)

NOTE: If your office does not house this information, please forward this request to the appropriate personnel.

Fax or Mail records to:

Requested by Registrar: _________________________________________________________________________________ Signature

Disclosure of Current Disciplinary Orders and Criminal History

Is this student currently serving a suspension or expulsion from another school?

□ Yes □ No

Has this student ever been adjudicated guilty of the commission of a class A designated felony act or class B designated felony act, as defined in OCGA 15-11-2? (A list of class A and class B designated felony acts is provided on the back of this form.)

□ Yes □ No

**If you answered yes to either question above, please provide the reason and terms for the suspension, expulsion, adjudication, or conviction. Parental Consent for Release of Records My consent is given for my child’s records and/or all other pertinent information to be released to the Effingham County School District. All information obtained will be kept strictly confidential. I give permission for Effingham County School District to obtain verbal clarification on any information received. ________________________________ ________________________________ ____________ Parent/Guardian Printed Name Parent / Guardian Signature Date According to Georgia Department of Education policy, personally identifiable data utilized in making and maintaining placement in special education programs may be transferred to another school system (in or out of state) which the child plans to attend.

Designated Felony Acts Excerpt from Official Code of Georgia § 15-11-2

(12) “Class A designated felony act” means a delinquent act committed by a child 13 years of age or older which, if committed by an adult, would be one or more of the following crimes:

(A) Aggravated assault in violation of paragraph (1), (3), or (4) of subsection (b) or subsection (d), (e), (f), (j), or (m) of Code Section 16-5-21 or assault with a deadly weapon or with any object, device, or instrument which, when used offensively against a person, actually does result in serious bodily injury;

(B) Aggravated battery; (C) Armed robbery not involving a firearm; (D) Arson in the first degree; (E) Attempted murder; (F) Escape in violation of Code Section 16-10-52, if such child has previously been adjudicated to have committed a class A designated

felony act or a class B designated felony act; (G) Hijacking a motor vehicle; (G.1) Home invasion in the first degree; (H) Kidnapping; (I) Participating in criminal gang activity, as defined in subparagraphs (A) through (G) and (J) of paragraph (I) of Code Section 16-15-3, in

violation of Code Section 16-15-4; (J) Trafficking of substances in violation of Code Section 16-13-31 or 16-13-31.1; (K) Any other act which, if committed by an adult, would be a felony in violation of Chapter 5 or 6 of Title 16, if such child has three times

previously been adjudicated for delinquent acts all of which, if committed by an adult, would have been felonies in violation of any chapter of Title 16, provided that the prior adjudications of delinquency shall not have arisen out of the same transaction or occurrence or series of events related in time and location; or

(L) Any other act which, if committed by an adult, would be a felony, if such child has three times previously been adjudicated for delinquent acts all of which, if committed by an adult, would have been felonies in violation of any chapter of Title 16 and one of which, if committed by an adult, would have been a felony in violation of Chapter 5 or 6 of Title 16, provided that the prior adjudications of delinquency shall not have arisen out of the same transaction or occurrence or series of events related in time and location.

(13)”Class B designated felony act” means a delinquent act committed by a child 13 years of age or older which, if committed by an adult, would be one or more of the following crimes:

(A) Aggravated assault in violation of subsection (g), (h), or (k) of Code Section 16-5-21 or assault with a deadly weapon or with any object, device, or instrument which, when used offensively against a person, would be likely to result in serious bodily injury but which did not result in serious bodily injury;

(B) Arson in the second degree; (C) Attempted kidnapping; (D) Battery in violation of Code Section 16-5-23.1, if the victim is a teacher or other school personnel; (E) Racketeering in violation of Code Section 16-14-4; (F) Robbery; (F.1) Home invasion in the second degree; (G) Participating in criminal gang activity, as defined in subparagraph (H) of paragraph (I) of Code Section 16-15-3, in violation of Code

Section 16-15-4; (H) Smash and grab burglary; (I) Possessing, manufacturing, transporting, distributing, possessing with the intent to distribute, or offering to distribute a destructive

device in violation of Code Section 16-7-82; (J) Distributing certain materials to persons under the age of 21 in violation of Code Section 16-7-84; (K) Any subsequent violation of Code Sections 16-8-2 through 16-8-5 or 16-8-5.2 through 16-8-9, if the property which was the subject of

the theft was a motor vehicle and such child has had one or more separate, prior adjudications of delinquency based upon a violation of Code Sections 16-8-2 through 16-8-5 or 16-8-5.2 through 16-8-9, provided that the prior adjudications of delinquency shall not have arisen out of the same transaction or occurrence or series of events related in time and location;

(L) Any subsequent violation of Code Section 16-7-85 or 16-7-87, if such child has had one or more separate, prior adjudications of delinquency based upon a violation of Code Section 16-7-85 or 16-7-87, provided that the prior adjudications of delinquency shall not have arisen out of the same transaction or occurrence or series of events related in time and location;

(M) Any subsequent violation of subsection (b) of Code Section 16-11-132, if such child has had one or more separate, prior adjudications of delinquency based upon a violation of subsection (b) of Code Section 16-11132, provided that the prior adjudications of delinquency shall not have arisen out of the same transaction or occurrence or series of events related in time and location;

(N) An act which constitutes a violation of Code Section 16-11-127.1; (O) Any other act which, if committed by an adult, would be a felony in violation of any chapter of Title 16 other than Chapter 5 or 6 of

Title 16, if such child has three times previously been adjudicated for delinquent acts, all of which, if committed by an adult, would have been felonies in violation of any chapter of Title 16 other than Chapter 5 or 6 of Title 16, provided that the prior adjudications of delinquency shall not have arisen out of the same transaction or occurrence or series of events related in time and location.

Department of Exceptional Students Updated: June 2019

Effingham County Schools Request for Records/Transcripts

Special Education / 504 Plan Students

www.effinghamschools.com

TO: PHONE:

FROM: Effingham County BOE, Department of Exceptional Students DATE:

FAX: PHONE: (912) 754-5623 The student named below has entered our school district: Name: ________________________________________ Date of Birth: ______________ Grade:________ Student’s Previous Address: ___________________________________________________________________________ Previous School Attended: ____________________________________________________________________________ School District: _____________________________________________ City, State: ______________________________

*If student was enrolled in a Georgia Kindergarten program, in addition to providing requested records, please also have classroom teacher release students on GKIDS.

Please fax or mail the following records for enrollment. Please do not send originals. NOTE: According to Georgia DOE Board Rule 160-5-1-.14, schools must mail or otherwise deliver requested records within 10 calendar days of receipt of request. Schools shall not withhold any student record because of nonpayment of fees.

• Speech Records• Special Education Records (IEP/Eligibility/Psychological Evaluation or Reports)• Documentation related to commission of any felony offenses• 504 (active or inactive)

NOTE: If your office does not house this information, please forward this request to the appropriate personnel.

Fax, Mail, or Email records to: Dr. Lindsay Blakey, BOE/Department of Exceptional Students or the school registrar 405 N. Ash Street Springfield, GA 31329

lblakey@effingham.k12.ga.us FAX: 912-330-2517

Requested by: ______________________________________________________________________________________________________________ Signature/Title

Disclosure of Current Disciplinary Orders and Criminal History Is this student currently serving a suspension or expulsion from another school?

□ Yes □ No

Has this student ever been adjudicated guilty of the commission of a class A designated felony act or class Bdesignated felony act, as defined in OCGA 15-11-2?(A list of class A and class B designated felony acts is provided on the back of this form.)

□ Yes □ No

**If you answered yes to either question above, please provide the reason and terms for the suspension, expulsion, adjudication, or conviction.

Parental Consent for Release of Records My consent is given for my child’s records and/or all other pertinent information to be released to the Effingham County School District. All information obtained will be kept strictly confidential. I give permission for Effingham County School District to obtain verbal clarification on any information received. ________________________________ ________________________________ ____________ Parent/Guardian Printed Name Parent / Guardian Signature Date

According to Georgia Department of Education policy, personally identifiable data utilized in making and maintaining placement in special education programs may be transferred to another school system (in or out of state) which the child plans to attend.

Please complete ONLY if your child was served in the Special Education Program or had a 504 Plan at the previous school.

Records/Transcripts

Department of Exceptional Students Updated: June 2019

Designated Felony Acts Excerpt from Official Code of Georgia § 15-11-2

(12) “Class A designated felony act” means a delinquent act committed by a child 13 years of age or older which, if committed by an adult, would be one or more of the following crimes:

(A) Aggravated assault in violation of paragraph (1), (3), or (4) of subsection (b) or subsection (d), (e), (f), (j), or (m) of Code Section 16-5-21 or assault with a deadly weapon or with any object, device, or instrument which, when used offensively against a person, actually does result in serious bodily injury;

(B) Aggravated battery; (C) Armed robbery not involving a firearm; (D) Arson in the first degree; (E) Attempted murder; (F) Escape in violation of Code Section 16-10-52, if such child has previously been adjudicated to have committed a class A designated

felony act or a class B designated felony act; (G) Hijacking a motor vehicle; (G.1) Home invasion in the first degree; (H) Kidnapping; (I) Participating in criminal gang activity, as defined in subparagraphs (A) through (G) and (J) of paragraph (I) of Code Section 16-15-3, in

violation of Code Section 16-15-4; (J) Trafficking of substances in violation of Code Section 16-13-31 or 16-13-31.1; (K) Any other act which, if committed by an adult, would be a felony in violation of Chapter 5 or 6 of Title 16, if such child has three times

previously been adjudicated for delinquent acts all of which, if committed by an adult, would have been felonies in violation of any chapter of Title 16, provided that the prior adjudications of delinquency shall not have arisen out of the same transaction or occurrence or series of events related in time and location; or

(L) Any other act which, if committed by an adult, would be a felony, if such child has three times previously been adjudicated for delinquent acts all of which, if committed by an adult, would have been felonies in violation of any chapter of Title 16 and one of which, if committed by an adult, would have been a felony in violation of Chapter 5 or 6 of Title 16, provided that the prior adjudications of delinquency shall not have arisen out of the same transaction or occurrence or series of events related in time and location.

(13)”Class B designated felony act” means a delinquent act committed by a child 13 years of age or older which, if committed by an adult, would be one or more of the following crimes:

(A) Aggravated assault in violation of subsection (g), (h), or (k) of Code Section 16-5-21 or assault with a deadly weapon or with any object, device, or instrument which, when used offensively against a person, would be likely to result in serious bodily injury but which did not result in serious bodily injury;

(B) Arson in the second degree; (C) Attempted kidnapping; (D) Battery in violation of Code Section 16-5-23.1, if the victim is a teacher or other school personnel; (E) Racketeering in violation of Code Section 16-14-4; (F) Robbery; (F.1) Home invasion in the second degree; (G) Participating in criminal gang activity, as defined in subparagraph (H) of paragraph (I) of Code Section 16-15-3, in violation of Code

Section 16-15-4; (H) Smash and grab burglary; (I) Possessing, manufacturing, transporting, distributing, possessing with the intent to distribute, or offering to distribute a destructive

device in violation of Code Section 16-7-82; (J) Distributing certain materials to persons under the age of 21 in violation of Code Section 16-7-84; (K) Any subsequent violation of Code Sections 16-8-2 through 16-8-5 or 16-8-5.2 through 16-8-9, if the property which was the subject of

the theft was a motor vehicle and such child has had one or more separate, prior adjudications of delinquency based upon a violation of Code Sections 16-8-2 through 16-8-5 or 16-8-5.2 through 16-8-9, provided that the prior adjudications of delinquency shall not have arisen out of the same transaction or occurrence or series of events related in time and location;

(L) Any subsequent violation of Code Section 16-7-85 or 16-7-87, if such child has had one or more separate, prior adjudications of delinquency based upon a violation of Code Section 16-7-85 or 16-7-87, provided that the prior adjudications of delinquency shall not have arisen out of the same transaction or occurrence or series of events related in time and location;

(M) Any subsequent violation of subsection (b) of Code Section 16-11-132, if such child has had one or more separate, prior adjudications of delinquency based upon a violation of subsection (b) of Code Section 16-11132, provided that the prior adjudications of delinquency shall not have arisen out of the same transaction or occurrence or series of events related in time and location;

(N) An act which constitutes a violation of Code Section 16-11-127.1; (O) Any other act which, if committed by an adult, would be a felony in violation of any chapter of Title 16 other than Chapter 5 or 6 of

Title 16, if such child has three times previously been adjudicated for delinquent acts, all of which, if committed by an adult, would have been felonies in violation of any chapter of Title 16 other than Chapter 5 or 6 of Title 16, provided that the prior adjudications of delinquency shall not have arisen out of the same transaction or occurrence or series of events related in time and location.