New Enrollment Form 2012 Chester (Page 2 of 3) in pdf

HESTER

OUNTY

Chester Park School of the Arts (K-5)

Great Falls Elementary School (PK-5)

CHOOLS

C P Center of Literacy through Technology (K-5)

Lewisville Elementary School (PK-5)

REQUESTING

509 D

ISTRICT

FFICE

RIVE

Chester Park School of Inquiry (PK-5)

ENROLLMENT IN:

, SC 29706

HESTER

Chester Middle School (6-8)

Chester Senior High (9-12)

: (803) 385-6122

HONE

Great Falls Middle School (6-8)

Lewisville High School (9-12)

: (803) 581-0863

Lewisville Middle School (6-8)

Great Falls High School (9-12)

CHECK ONE

Alternative Education (6-12)

STUDENT INFORMATION

--Please Print Clearly--

Date:

Has student ever attended Chester County Schools?

Year(s):_____________

YES

NO

_ _ _ - _ _ - _ _ _ _

Social Security Number (Optional

Gender: Male

Grade: ___________

Female

Legal Name: ____________________________________________________________________________________________

Last

First

Middle

Called

Address: ___________________________________________________ City/State/Zip: ________________________________

Mailing Address: _____________________________________________ City/State/Zip: ________________________________

Old Address: ________________________________________________ City/State/Zip: ________________________________

)

_ _ - _ _ - _ _ _ _

Phone #: _____________________ Birth Date (MM/DD/YYYY

Medicaid #:___________________

ETHNIC GROUP AND CATEGORIES: The federal government requires that questions 1-5 are answered.

1) Ethnicity: (CHECK ONE)

2) Race: (CHECK ALL THAT APPLY)

 Hispanic

 American Indian/Alaskan Native  Black/African American

 White/Caucasian

 Not Hispanic/Latino

 Asian

 Hawaiian/Other Pacific Islander

3) Country of Birth:

4) Date child entered US Schools:

5) Language: What language did your child

first learn to speak?

Is the student identified as a student with special needs and being served with an IEP, 504 Plan, Gifted Education Services?

Check Any that Apply

504 Plan

IEP

Gifted

Learning Disability

Emotional Disability

Physical Handicap or

Speech/Language

Hearing

Vision

Other Health Impairment__________________________________

GUARDIAN/CUSTODIAL INFORMATION

With whom does the student live?

Both Parents

Both Parents Alternately

Foster Family

Father

Mother

Legal Guardian__________________________

Independent

Homeless

The custody of a child is presumed to be held by the child’s parents unless a court order states otherwise. Even in divorce situations, it is presumed that both parents

will have joint legal custody of the child. That is, they will share equally in all important decisions such as medical and educational decisions. If one parent informs

the school district that the other parent is denied custody or visitation, that parent must provide a copy of the court documents as proof.

Copy of Court Order Provided:



yes



PARENT/GUARDIAN 1

PARENT/GUARDIAN 2

Mother

Father

Name: (First Last) __________________________________________

_________________________________________

Other