Erlanger-Elsmere School District Enrollment/Information Update Form 2013-14 Pg.

1
http://www.erlanger.kyschools.us

School:______________________________________ Student Information

Grade:_____________

Legal Name of Student: (First, M, Last)______________________________________________________ Gender:___ Date of Birth:______ Check for 1st time enrollment in a Kentucky School Student Nickname:___________________________ Birth Place:__________________________ (Birth Certificate or other reliable proof of birth required by State Law 158.032) Ethnicity (must choose one): Hispanic/Latino or Not Hispanic/Latino (choose all that apply): White: Black: Asian: American Indian/Native Alaskan: Native Hawaiian/Other Pacific Islander: Household Phone #: _______________ Household Address: _________________________________ (City) ____________ (Zip) _____ Household Mailing Address (IF DIFFERENT):____________________________________ (City)__________________________ (Zip)______ Has your child ever been enrolled in a Kentucky School? No: ____ Yes: ____ Last school attended: ________________________________ Last school address: _________________________________________________________________________________________________ To participate in Kentucky Educational Excellence Scholarship (KEES) program in high school, students social security card MUST be on file.

Parents/Guardians Living in same Household as Student (Students Primary Household)

Legal Name: _________________________________Suffix: _____ Relationship to Student: _______________________ Phone: Other (____)_____________Work: (____)______________ Cell Phone: (____)_______________ E-Mail __________________ Place of Employment: ____________________________________ Legal Name: _________________________________Suffix: _____ Relationship to Student: _______________________ Phone: Other (____)_____________Work: (____)______________ Cell Phone: (____)_______________ E-Mail __________________ Place of Employment: ____________________________________

School-Aged Siblings Living in Same Household as Student

Legal Name:___________________________________ Age:_____ School Attending: ___________________________Grade:___________ Legal Name:___________________________________ Age:_____ School Attending: ___________________________Grade:___________

Legal Parent/Guardian Living at a Different Address from Student (Secondary Household)

1) Legal Name: _______________________________ Suffix: ____ Relationship to Student: _______________________ Does this parent/guardian have joint custody? ________ Address: _______________________________________________ City: _________________________ State: ______ Zip: __________ Phone: Home (____)_____________Work: (____)______________ Cell Phone: (____)_______________ E-Mail __________________ Place of Employment: ____________________________________ 2) Legal Name: _______________________________ Suffix: ____ Relationship to Student: _______________________ Does this parent/guardian have joint custody? ________ Address: _______________________________________________ City: _________________________ State: ______ Zip: __________ Phone: Home (____)_____________Work: (____)______________ Cell Phone: (____)_______________ E-Mail __________________ Place of Employment: ____________________________________

Emergency Contacts (People Authorized to Pick Student Up From School (up to 3)

Name:________________________________Relation:___________________Phone 1 :_________________Phone 2:_________________ Name:________________________________Relation:___________________Phone 1 :_________________Phone 2:_________________ Name:________________________________Relation:___________________Phone 1 :_________________Phone 2:_________________

Student Safety
If there is anyone NOT ALLOWED access to this student, list his/her name and relationship (Legal documentation must be provided to the school). Name: _________________________________________ Relationship to student: ______________________________________

Medical/Physician Information and/or KCHIP Information and/or Medical Care

Doctor:_____________________________ Phone:_______________ Dentist:___________________________ Phone:_______________ Do you have health insurance? No: Yes: Medicaid: No: Yes: KCHIP: No: Yes: Medications/Allergies/Medical Conditions:______________________________________________________________________________
It is the legal parent/guardians responsibility to send in writing any pertinent information each year to the school office about serious health conditions.

Erlanger-Elsmere School District Enrollment/Information Update Form 2013-2014 Pg. 2

Special Services. Please check any special programs in which the student has participated. Speech/Language IEP (Special Education) 504 Plan Gifted/Talented Home Language Survey (If other than English, please complete the following 4 questions). 1. What language is most frequently spoken at home? ________________________ 2. What language did your child learn when he/she first began to speak? ____________________ 3. What language does your child most frequently speak at home? ____________________ 4. In what language do you most frequently speak to your child? __________________________ Has your child ever been adjudicated guilty or previously expelled for homicide, assault or violations relating to weapons, alcohol, or drugs? NO: YES . KRS 158 requires that a parent/guardian report this conduct to school officials on the Erlanger-Elsmere Schools Disclosure/Compliance
Form and verbally. (Please ask school administration for this form).

Is your child currently under suspension from previous school? NO

YES

Parent/Guardian and Student Authorizations. Please check all that apply. __ I acknowledge receipt of and accept school codes of conduct, including a) the Discipline Code, 2) the Dress Code, and 3) the school Medication Policy. __ I acknowledge receipt of and accept the district Acceptable Use Policy, and agree for my child to have access to the Internet. In lieu of signing and returning the Student User Contract on the final page of the AUP, the check to the left and my signature below indicate my agreement with all of the statements in the Yes section of the Student User Contract. __I acknowledge receipt of district Bring Your Own Device Responsible Use Guidelines, and in lieu of signing the BYOD signature sheet, by checking here I give permission for my child to bring a personal technology device to school, and my child and I agree to abide by those guidelines. __ In an emergency, I give the school district permission to evacuate my child from the school premises. __ (Grades 9-12 only) I give permission for my childs contact information to be released to military recruiters. __ I give permission for the school district to share the Free/Reduced Meal Eligibility status only of my child with the Erlanger-Elsmere Schools Family Resource Centers/Youth Service Centers in order to assist in determining families in need. I understand that the FRC/YSC Centers will NOT share this information with any other entity or program. I further understand that failing to check the box to the left will NOT affect my childs ability to participate in FRC/YSC programs. __ I acknowledge receiving information regarding my rights under the Federal Educational Rights and Privacy Act. __ (Grades 6-12 only) I acknowledge receiving the Individual Learning Plan Web Release form from my school, and in lieu of returning the Signature sheet on that form, I hereby acknowledge that I have read and understood that form, and authorize the District to enable a Feature of the ILP which will permit my student to invite third parties to have access to his/her ILP information.
Do you have a computer at home: Yes _____ No _____ If yes, do you have internet access? Yes _____ No _____ If yes, to Internet Access, who is your Internet Service provided by? Cable Company ___ Satellite Dish ___ Phone Company (fast/high speed) ___ Phone Company (slow/dial up) ___ Other ___

I, as legal parent/guardian, hereby state that the information contained on both sides of this form is accurate to the best of my knowledge. I authorize the school district to share pertinent medical information with school staff, paraprofessionals, coach volunteers and emergency personnel and to seek medical assistance for my child in an emergency. Parent/Guardian Signature: ___________________________________________________Date:____________ I, as the enrolling student, hereby agree to abide by all of the policies checked above. Student Signature (grade 4 and above):__________________________________________Date:____________

For Office Use Only

___ Birth Certificate ___ Immunizations ___ Physical ___ SSN ___ Lease/Proof of Residency ___ Transportation Code ___ HR

Entry Date: __________________________

Initial ________________

STUDENTS

09.14 AP.251

Publication Consent Form

PLEASE COMPLETE THIS FORM AND SUBMIT IT TO THE SCHOOL. Dear Parent/Guardian: At some time during the school year, school/District personnel or other District-authorized persons may videotape or photograph classroom activities or special projects in which your child participates during or after the school day for public awareness or fund-raising purposes. This form covers permission for the District to record and use the recorded image, voice, or work of the student (photographed, filmed, taped, or digitally recorded) for public awareness purposes, including publication on the school and/or Districts web site and in school yearbooks. Please review this form carefully, sign and date the form, and submit the form to the school. Once signed and dated, this form shall remain in effect for your childs enrollment in the District schools. However, at any time during the school year, you may amend this form only for future uses/preferences by notifying the Principal in writing of your request. As the parent(s)/guardians(s) of __________________________________, I/we give the Students Name ______________________________ School District permission to release my/our childs name, Districts Name photograph, work, and/or audio/video reproduction for publication to the general public concerning school functions and activities, including academic and athletic activities. Name of Parent(s)/Guardian(s) (Please print.) ______________________________________ ____________________________________________________ Parent/Guardians Signature ___________________ Date

NOTE: If the recorded image, voice, or work of a student is to be included in a publication as part of a commercial or for-profit fund-raising endeavor, affirmative authorization of the parent/guardian or eligible student must be obtained. Review/Revised:6/25/13

STUDENTS

09.14 AP.12

Student Directory Information Notification

Consistent with the Family Educational Rights and Privacy Act (FERPA), parents (or students 18 or older) may direct the District not to disclose directory information listed below. We are required to disclose a students name, address, and telephone listing at the request of Armed Forces recruiters, unless a parent or secondary school student, regardless of age, requests that this information not be disclosed. _______________________ Date
Dear Parent/Eligible Student, This letter informs you of your right to direct the District to withhold release of student directory information for _______________________________________________. Following is a list of items that the District considers Students Name student directory information. If you wish information to be withheld, please choose one (1) of the two (2) options below in both Sections I and II. Choose Option 1 if the District may not release any item of directory information; Option 2, if the District may release only selected items of information. Then check those items that may be released. Please be advised that parents cannot prevent the school from using directory information on District-issued ID cards or badges. If we receive no response within thirty (30) days of the date of this letter, all student directory information will be subject to release without your consent. If you return this signed form on time, we will withhold the directory information consistent with your written directions, unless disclosure is otherwise required or permitted by law. Once there has been an opt-out of directory information disclosure, the District will continue to honor that opt-out until the parent or the eligible student rescinds it, even after the student is no longer in attendance. Student Directory Information Listing Section I Section II Third Parties, Limited to Institutions of Higher Education Armed Forces Recruiters (Parent or secondary school student, regardless of & Potential Employers (Parent or student 18 or older may sign below to direct the District to age, may sign below to direct the District to withhold information in this section.) withhold information in this section.) CHOOSE ONE OF THE OPTIONS BELOW: Choose one of the Options below: Option 1: The District MAY NOT RELEASE ANY information listed Option 1: The District MAY NOT RELEASE below. ANY information listed below. Option 2: The District MAY RELEASE ONLY the information Option 2: The District MAY RELEASE checked below. ONLY the information checked below. If you choose Option 2, check the item(s) of information listed below that the District may release. Students name Students address Students school email address Students telephone number Students date and place of birth Students major field of study Information about the students participation in officially recognized activities and sports Students weight and height (if a member of an athletic team) Students dates of attendance Degrees, honors and awards the student has received Students photograph/picture Most recent educational institution attended by the student Grade level If you choose Option 2, check the item(s) of information listed below that the District may release. Students name Students address Students telephone number (if listed)

NOTE: IF DIRECTED TO WITHHOLD A STUDENTS NAME, GRADE LEVEL, OR PHOTOGRAPH, THAT INFORMATION WILL NOT BE INCLUDED IN ANY SCHOOL OR DISTRICT PUBLICATION RELEASED TO THE PUBLIC. A PARENT WISHING TO PERMIT SUCH INFORMATION ABOUT HIS/HER CHILD (NAME, PICTURE, ETC.) TO BE INCLUDED IN A SCHOOL OR DISTRICT PUBLICATION (YEARBOOK, SPORTS PROGRAM, ETC.) THAT IS SOLD FOR FUND-RAISING PURPOSES MUST PROVIDE WRITTEN CONSENT FOR SUCH PURPOSES.

_________________________________________________
Parent/Student Signature

__________________
Date

Review/Revised:6/25/13