New Enrollment Form 2012 Chester Page 3
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RESIDENCY INFORMATION
Where is the student currently living? (Please check ONE box.)
In permanent housing
With another family or other person because of loss of housing or as a result of economic hardship
In a shelter
(sometimes referred to as “doubled-up)
In a hotel/motel
Other temporary living situation
Please describe:___________________________________
In a car, park, bus, train, or campsite
EMERGENCY NOTIFICATION/PERSONS ALLOWED TO SIGN STUDENT OUT OF SCHOOL
In case of a medical emergency and I cannot be reached directly, the school has my permission to call/and or release my child to the following
individuals. Please notify school as changes occur. (We will not release your child to anyone who is not on the list)
THE ADULTS LISTED BELOW ARE THE ONLY ONES ALLOWED TO PICK UP MY CHILD FROM SCHOOL.
1.
____________________________________
Phone Number_______________________
Relation to Child____________________
2.
____________________________________
Phone Number_______________________
Relation to Child____________________
3.
____________________________________
Phone Number_______________________
Relation to Child____________________
4.
____________________________________
Phone Number_______________________
Relation to Child____________________
5.
____________________________________
Phone Number_______________________
Relation to Child____________________
Health Problems/Medical Conditions: Yes No: If yes, please explain: __________________________________________________________
_________________________________________________________________________________________________________________
Medication taken during school hours: ____________________________________________________________________________________
_________________________________________________________________________________________________________________
Family Physician: ______________________________________________
Telephone: _______________________________________
PREVIOUS SCHOOL INFORMATION
Please list all schools that your child has attended in the last 12 months:
SCHOOL 1
SCHOOL 2
School: _______________________________________________
School: ________________________________________________
Address: ______________________________________________
Address: _______________________________________________
City/State/Zip: __________________________________________
City/State/Zip: ___________________________________________
Phone: ________________________________________________
Phone: ________________________________________________
Was the student expelled? Yes No
Was the student expelled? Yes No
If yes, for what reason: ____________________________________
If yes, for what reason: _____________________________________
Reason for leaving previous school: __________________________
Reason for leaving previous school: ___________________________
_____________________________________________________
______________________________________________________
SIBLING INFORMATION
Other Brothers or Sisters in Chester County Schools:
Name
School
Grade
Name
School
Grade
1. _________________________________________________
3. _____________________________________________________
2. _________________________________________________
4. _____________________________________________________
_____________________________________________________________________________________________________________________________________________________________
Parent/Guardian Signature
Date
Chester County School District does not discriminate on the basis of age, gender, race, religion, handicapping conditions, immigrant status, English-speaking status, or
national origin. This is in compliance with Title VI, Title VII, Title IX, Section 504, Americans with Disabilities Act (ADA), and all other applicable Civil Rights Laws.
OFFICE USE ONLY
Documents Presented: Birth Certificate/Other Proof of Birth: ___________________________
Immunization Record
Custody Papers
Social Security Card
Proof of Residency
Affidavit of Residence
Homeless Student
Foster Child
Unaccompanied Youth
Request for enrollment is:
Home Visit Date: __________________
Approved
_____________________
Denied for the following:
____________________
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________
Attendance Supervisor/School Personnel
Revised 5/1/2012; supersedes all previous versions.
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