2015-2016

DeKalb CountySchool District

sccnotc ).-]JJ'i marv .F-!t)? tsehol .tPrevious DeKalb County School System

DYes o No Has any household member already been enrolled in a DeKalb County School?

Who has legal custody?:

OBoth Parents OFather OMother DGrandparent(s) OWard of CourtO*Legal Guardian (*Must provide school with copy of Legal Papers)

With whom does the child primarily live?:

OBoth Parents OFather Only OMother Only OFather & Stepmother OMather & StepfatherO*Legal Guardian (*Must provide school with copy of Legal Papers)

Primary Household Information - Where student normally sleeps on a nightly basis

Physical Address(Street Number) (Street Name)

City: State: Zip:

Mailing Address (If different than physical address)

City: State: Zip:

Mail should be addressed to (as listed below): 0 Legal Guardian One o Legal Guardian Two

Primary Phone: ( ) -(Note: the primary phone number will be utilized for communications.)

Primary Household Parent / Legal Guardian 1:

(Last) (First) (Middle) Suffix (Jr, Sr, II, III, etc.)

Relationship to Student(s): (Mother, Father, Grandparent, Guardian, etc)

E-Mail Address:

Cell Phone # ( ) - Work phone # ( ) -

Emergency Call Sequence DPortal

Primary Home Language Dialect

First Language Spoken Correspondence Language

DTranslation Services Needed DActive Duty in US Armed Forces (includingNational Guard & ReserveForces)

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DeKalb CountySchool District

Primary Household Parent / Legal Guardian 2:

(Last) (First) (Middle) Suffix (Jr, Sr, II, III, etc)

Relationship to Student(s): (Mother, Father, Grandparent, Guardian, etc)

E-Mail Address:

Cell Phone # ( ) - Work phone # ( ) -

Emergency Call Sequence DPortal

Primary Home Language Dialect

First Language Spoken Correspondence Language

DTranslation Services Needed DActive Duty in US Armed Forces (includingNationalGuard & ReserveForces)

SECTlO,V 2.' Secondarv Household

Secondary Household Information - Where student sleeps on a part time basis.(Leave blank if this does not apply to your family situation)

Should this address receive written correspondence? DYes o No

Physical Address(Street Number) (Street Name)

City: State: Zip:

Mailing Address (If different than physical address)

City: State: Zip:

Secondary Household Parent / Legal Guardian 2:

(Last) (First) (Middle) Suffix (Jr, Sr, II, III, etc)

Relationship to Student(s): (Mother, Father, Grandparent, Guardian, etc)

E-Mail Address:

Cell Phone # ( ) - Work phone # ( ) -

Emergency Call Sequence DPortal

Primary Home Language Dialect

First Language Spoken Correspondence Language

DTranslation Services Needed DActive Duty in US Armed Forces (includingNational Guard & ReserveForces)

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;,-"DeKalb countySchool District

sccrto« .3.- Emergency Contact: IEmergencv Contacts - The following peoplehavepermissionto pick up my child(ren)from schoolwithout further contact

from me and in the event of an emergencywhen the ParenULegalGuardiancannot be reached.

Emergency Contact 1: Relationship

Cell # Home# Work #

Emergency Call Sequence OPortal Primary Home Language

Emergency Contact 2: Relationship

Cell# Home# Work #

Emergency Call Sequence DPortal Primary Home Language

Emergency Contact 3: Relationship

Cell # Home # Work #

Emergency Call Sequence DPortal Primary Home Language

f..'CCT'O!! 11· Additional Household Members (include all students and additional adults) I.JL ,L 1 ,\ ,.

Additional Household Members & Siblings - Please list the names of all additional householdmembers and siblings,

I I ILast Name First Name Age Relation to Student School

I I ILast Name First Name Age Relation to Student School

I I ILast Name First Name Age Relation to Student School

I I ILast Name First Name Age Relation to Student School

I i ILast Name first Name Age Relation to Student School

If there are custody issues that prevent any of the previously indicated heads of household from havingaccess to the students listed above, please provide details, If such restrictions apply to a natural parentor legal parent/guardian not listed on birth certificate, court documentation must be provided,

,SECTION 5: Si on a ture I- 0

Name of Parent/Legal Guardian completing Form (print):

Signature Date:

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DeKafb colint'ySchool District

2015-2016

SECTION 1: Student Information I

Student's Legal Name/ Vital Information:

(Last) (Middle) (Suffix)(First)

(Preferred First Name)

Date of Birth: / /--- ----'---- Gender: OM OF

Place of Birth:

City: State: Country: _

If born outside US:date arrived in US: ___ ,1 1__ -

first time in US School: ,/ ,1 _

Grade: ---- Date Entered 9th Grade (if applicable): 1 ,1 _

Social Security Number: (voluntary)

o I understand that my child's Social Security Number will be required for HOPE Scholarship eligibility.

Check one:

o Social Security Card Providedo I give permission to DeKalb County School District to obtain my child's social security numberfrom the Georgia Department of Education's database.o I do not wish to have my child's Social Security Number placed into school records, and Idecline the request to provide a copy of the Social Security Card.

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DeKalb CountySchool District

Federally Mandated Questions: Please answer both parts

Part A - Ethnicitv: Is the student Hispanic or Latino? (choose only one)

D No, not Hispanic/LatinoDYes, Hispan ic/Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American,

or other Spanish culture or origin, regardless of race).

The above part of the question is about ethnicity, not race. No matter what yOU selected above, pleasecontinue to Pari B.

Answer the fol/owing bv marking one or more boxes to indicate what yOU consider this student's race to be.

Part B - Race: What is the student's race? (choose all that apply)

oAmerican Indian or Alaska Native (A person having origins in any of the original peoples ofNorth and South America (including Central America), and who maintains tribal affiliation orcommunity attachment.)

D Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, or theIndian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia,Pakistan, the Philippine Islands, Thailand, and Vietnam.)

D Black or African American (A person having origins in any of the black racial groups of Africa.)

D Native Hawaiian or Other Pacific Islander (A person having origins in any of the originalpeoples of Hawaii, Guam, Samoa, or other Pacific Islands.)

D White (A person having origins in any of the original peoples of Europe, the Middle East, or NorthAfrica.)

School Use Only:

OParent Refused OParent Non-ResponsiveReason for Observation:

DBoth Parts DPart A Only DPart B OnlyObserver Completed:

DateObserver's Name Observer's Signature

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DeKalb CountySchool District

1. What language does this student speak most often at home?

2. What was the first language this student learned to speak?

3. List Dialect (if applicable)

(~r'C~]·'7()\' 4 n I 'S I I TJ .•.')0 1,. Stua cnt 's ·c.wo History

Did your child attend any of the following?

DGeorgia PK Program - Public SchoolDPublicly - Sponsored (Title I)DHead StartDOther Public School

DPrivate - not for profitDPrivate - for profitDNo Pre-K ProgramOGeorgia PK Program - Private School

School previously attended:

Name of school:

Address:

Date of Last Day Attendance: 1 1 _

SPECIAL PROGRAMS

Was your child receiving any of the following support services?

DEarly Intervention Program (EIP)DGifted ProgramDResponse to Intervention-(RTI)/

Student Support Team (SST)DEnglish Language (EL)

DRemedial Ed Program (REP)DSection 504 PlanOTitle I Program (TA only - targeted assistance)DReadiness Class

Was your. child receiving special education services (IEP)? DYes DNa

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DeKalb CountySchool District

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'.'I,f·T!()· 7-()-· 'T'V(!·"'nI1l.'l··1,· >!' '7""';'1,'1J.....IL.; ••.__-.z..L _,!¥ . 1, UtL.)jJ'J; ,{)t 6:1 )~/./....,

Indicate student's primary intent for transportation:

Morning:

DBus Rider DCar Rider DWalker DDay Care Bus DStudent Driver

Afternoon:

DBus Rider DCar Rider DWalker DDay Care Bus DStudent Driver

EMERGENCY CLOSING INSTRUCTIONS

Should school be dismissed early, we need to know if your child is to ride the bus, go to day care, or be

picked up by you, Weather, plumbing, electrical problems or other emergencies could cause us-to dismiss

early. It is important that arrangements are made in case of these unforeseen events. Sometimes our

phone lines are busy so we cannot rely on a last minute phone call for directions. If the need to close

early occurs, our elementary leveled schools would call all day care centers that pick up from their school.

CHECK ONE:

D Ride Regular Bus HomeD Parent Pick-upD Other (please explain):

Thank you. We hope we do not need this information. Please discuss this plan with your child.

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---~~.DeKalb CountySchool District

\E'('TfON 6: Health

Physical Conditions or Concerns:

ALLERGIES DYes DNa ASTHMA DYes DNa

DIABETES DYes DNa SEIZURE DISORDER DYes DNo

If you answered yes to any of the above, please detail specifics in space provided along with any otherphysical or mental health issues which may be a concern at school.

ODoes your child take any prescribed medications routinely? List

SECTION 7.- Discipline

Discipline

DYes DNa: Is this student under a current expulsion or suspension orderfrom this or another school system?

DYes DNo: Has this student ever been expelled?

If Yes to either of the above, please fill out the following information:

Reason for Expulsion:

School system:

Date Expelled or Suspended:

DYes DNa: Has this student been adjudicated delinquent or convicted ofmurder, voluntary manslaughter, rape, aggravated sodomy,aggravated child molestation, aggravated battery, or armedrobbery?

If Yes, where did this offense occur?

I ICourt County State

ANY PERSONWHO KNOWINGLYPROVIDESFALSE INFORMATIONOR DOCUMENTATIONIN CONNECTIONWITH THE REGISTRATIONOF A STUDENTMAY BE CRIMINALLYLIABLEUNDER O.C.G.A. 16-10-20. SHOULD SCHOOL OFFICIALS DETERMINE THAT FALSEINFORMATIONOR DOCUMENTATIONHAS BEEN SUBMITTED,A REPORTWILL BE FILEDWITH THEAPPROPRIATELAW ENFORCEMENTOFF!CIALS.

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DeKalb CountySchool District

Please read and initial the following:

I am authorized to enroll this student, and understand that in compliance with OCGA 20-2-780that having enrolled the student, I am the only person who can withdraw the student, unless acourt 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 toprovide Form 3231 within the time specified on the Notification of Waiver form.

This student is NOT currently on suspension or expulsion status from another school.

I understand that this student's enrollment is contingent, pending receipt of all disciplinary recordsfrom aAYprior schools attended.I understand that if this student is being provisionally enrolled in __ grade without all requireddocumentation, this student is being provided educational services based solely on theinformation I provide. I understand that changes may be made to the services being providedonce records are received from previous schools and have been reviewed by appropriate schoolpersonnel. This may include, but is not limited to, grade placement, class placement, teacherassigned, type of instructional setting, and any other changes that the school administrationdeems necessary.

In the event of an emergency I acknowledge that a school representative will take necessaryactions to secure medical treatment for my child at the closest available medical provider ormedical facility. I acknowledge that such actions may incur charges for which I am responsible.

My relationship to the student is:OBiological Parent (Step-parents are not allowed to complete the registration process without additional documents)

oLegal Guardian (documentation needed)

oPerson having lawful Court Order (copy required)

oOther (Non-Parental Affidavit required)

oSelf / Student (must be 18 years or older)

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

my know/edge.Printed Name: Date: _

Signature: _

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1701 Mountain Industrial BoulevardStone Mountain, GA 30083-1027678-676-1200

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DeKalb CountySchool District

www.dekalb.k12.ga.us

Media Release Form

I , agree to grant DeKalb CountySchool District and its assigns the right to use photo and/or video images and sound foruse as news and/or educational" programs including but not limited to videos thatpromote civic responsibility in whole or in part for any currently known media or mediato be developed.

I agree to release the DeKalb County School District from any and all claims, damages,liabilities and costs I now or might have regarding my appearance in association withnews stories and/or educational programs.

I hereby release all rights that I, my heirs, or assigns might have now or in the future toall or part of the said production, including but not limited to the publishing, printing,development, editing, and use in news papers and other forms of print media,broadcasting, cablecasting, webcasting, podcasting, video on demand, or any otherpublic or private presentation or screening purposes by the DeKalb County SchoolDistrict or its assigns.

I knowingly and willingly waive any and all rights or entitlements, including payments formy appearance or for the subsequent distribution of the products related to thisprogram.

Signature Date

Parent or Guardian Signature (if you are a minor) Date

DeKalb County School Representative Date

Watch: CH 24 on Comeast (DeKalb) orwww.pds24.tv

"The School Cannot Live Apart From The Community"www.deka\b.k12.ga.us

SCHOOL RE.ALTR CIJNIC rnFORMATION cARli} (School Year: 2014-2015)

DEKA.LB COUNTY SCHOOL DISTRICTSTUDENT HEALTH SERVICES

School Grade: TeacherlHR: =- _t="-

Name: -------------- Sex: M F D.O.R _

Address: -'-- Phone: (H) CC), evrj

Phone (H) (C) _Phone (W) Pgr, _

HEAL1;RHtsTGR-Y (Answer Yes or No, and give information as needed.)

Allergies (S-ped:Y) Diabetes,---, _Asthma Physical Disabilities '--_.A..DHDlADD. Sickle Cell,---c:-- _Cancer Seizure Disorder _Other phyc;,:;-1 '-"-L..!~1 health Issues which may be a concern at school: (continue on back as needed)

__ Does ye-ur Chilrl require spp."';~lseating in the classroom? Specify: ___ Does :v=chIld have any condition that would limit physical education activities? List: __ ~ ___ Does your c::ild take alij prescribed medications routinely? List -'- ____ Does your child take anynon-prescription medications? List: ___ Did your childreceive any immunizations this past year? List type, date: --'-- _

Date of last tetanus shot? _

II~i!

tI

List name(s).of school-age siblings:L Grade/School: _2. Grade/School: _3. Grade/School: _4.. Grade/School: _

E1fERGENCY CONTACT INFORMATION

F~cr/G~m~~ ~~-------:...~~=-.

Phone (H) ---:(C) _Phone (W) Pgr, _

If parents ~~~. 'S:;- ; ""l! "~.a' "'..,y p=ons ",,110 will assume care of your child.Name Relationship Phone _Name Relationship Phone _C-uild's~~der Phone _

I give y'~' .';; - .:. , ;., ~-..",-t;:;:;:y...::..Jd's healthcare provider for further medical information. Yes__ No __I also -or_:'" ,,_, •..0 -+=;- in ~ ~ of an emergency and I can not be reached that the school will' nave =y ci:ri.litransported !D the ~'j'-D' ~;" ivia fu:e:u.fS/911 serviceto receive appropriatetreatment

ParentS~ature ~ ~ Date _

PHYSIClA_N'S REQUEST FOR ADIYnNISTRA TION OF MEDICATIONAT SCHOOL BUILDING DURll~G SCHOOL HOURS

1. To keep this child in optimal health and to help maintain school performance, it is necessary thatmedication be given during school hours.

2. Nurses .and other designated school personnel can assist with self-administration of medication duringschool hours. .

3. In order for medication to be self administered at school, this form must be completed by licensedphysician and at least one guardian/parent and be returned to school.. .

School: ~ _

Name of child:-------~----~~-------DOB ~ _

Diagnosis: _ Infectious Noninfectious(please check one)

Allergies: _

Name of rnedication: Color, if applicable -'-_(Include trade name).

Form of medication to be given:

___ tablet pill capsule liquid inhalation ·injection** other (specify)** No injection will be given exceptin extreme emergency, such as allergy to wasp or bee sting or the like.

Dosage (amount to be given): .;,-- -r·1Frequency: ~--~------

~!

Common side effects: ~ ~_..,:..'= _

REMAJUKS: _

Physician's Name (print or type)Physician's Signature (date)

/Physician's Office PhonelFax#

This is your permission to give medication to my ·child named above as requested by the-physician.

/Parent's Signature (date) HomePhone# WorkPhone# ...

•r;

Email address Revised J % 7PagerlCel1#

Ronald E. Mclvair Discovery Learning AcademyParen tal Dismiss al Agreement

F or the safety and protection of each student, it is necessary that your child'steacher has a clear understanding concerning how your child leaves theschool each day. Therefore, you are requested to select the way that yourchild is to leave the school and to fill in other requested information whereapplicable.

If, fer specific reasons, you need to change your dismissal choice, youmust write your child's teacher a note. Telephone calls will not beaccepted.

Child's Name Date---------------------------------- -----------

Grade -------------- Teacher ------------------Ride School Bus Route # -------

Ride Nursery Bus _Name of Nursery Bus! Telephone Number

After SchoolProgram

WaIkHome

Car Rider

Name of Person, if not parent Telephone Number

Telephone NumberName of Person, if not parent

Signature ot Parent _

2013-2014

RONALD E. MCNAIR DISCOVERY LEARNINGACADEMY

Field Trip Permission Form

Educational and Cultural Arts field trips have a proper place in theinstructional program. They are scheduled as a definite outgrowth ofclassroom activity.

Teachers carefully plan each trip and present a proposal to the principalthat must be approved before the trip is scheduled. All necessarysupervisory and safety precautions will be taken.

Our students will be taking many field trips this year. Rather thansending home permission slips for each trip, we are requesting priorpermissions from the parents that will cover all of the trips this year.We feel this will be convenient for both you and the teachers. Pleasesign this form and return it to your child's homeroom teacher.

If for some reason, the parent decides that his or her child may notparticipate in a scheduled field trip during the school year. The parentshould notify the school in writing.

My child , has permission to attend anyapproved school field trips during this school year.

Parent/Guardian Date _