PONTIAC SCHOOLS OFFICIAL ENROLLMENT FORM

ETHNICITY: Is this student Hispanic/Latino Ethnicity (Choose Only One):

RACE: The previous question was regarding ethnicity, .not race. No matter what you selected to the left, please answer the following by marking one or more boxes to indicate what you consider your stud�nt's (or your) race to be: □ No, not Hispanic/Latino

□Yes, Hispanic/Latino (Cuban, Mexican, PuertoRican, South or Central American, or other

Do you speak a language In your home OTHER than English?

YES NO

If Yes, please note the language:

STUDENT PRIMARY LANGUAGE

Does your student speak a language In your home OTHER than English?

YES NO

If Yes, please note the language:

Has your child attended Pontiac Schools?

Did your child have an active IEP?

YES

YES

No

No

Birth ,Certincate: - -� Other Proof __

_________ ___;;

___

_ _

_ &:Affidavit _______________ _

Residency Verification: _______________ _ lD.etermlnaUvo / Corroborallva Type)

- Affidavit of StudentLiving w/Relalive: ____ _

- Affid11vit cif Famlly IJvhig w/Friend/Relative: __ _ _ _

Immunization Record: _______________ _

Homeless: ---ccc-----c---- ------ -----­(FTie peperwork w/Enrollment Offi1:<>)

Pontiac Enrollment Fann.pub - Revised February 2016

□American Indian □Asian □ Black/African American□Native Hawaiian/Other Pacific Islander □White

LEGAL BINDINGS: Please indlca!e any i!Petlal clrcumslances regarding your child,

HmRm # / Teacher: or Counselor:

Verified / Entered By:

Verifier Title: __________________ _

2020-2021 Pre K

PONTIAC SCHOOLS OFFICIAL ENROLLMENT FORM

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ferna!e ParenVGuardian 'Email Addres,s (General T!lb)

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PONTIAC SCHOOLS OFFICIAL ENROLLMENT FORM

List medical conditions (allergies, health conditions etc.) or other information which you want teachers and office person­nel to know. This information when entered, will be available for teachers to see in class on a secure desktop application.

D This is a critical alert item

By listing this information here, I agree to share this informa-tion with school officials. Parent/Guardian Initials __ _

Family. Insurance Provider

ln�urance Polic;y Number

,-:-;;-ll,:\ Great Start Readiness Program Application ;:&'�adlness '?roBrarn

J Mlif'.� r"1Mt...1,1l!fy ll'utMplfrid ,rr i. ri�a"' Child must be 4 years old on or before September 1st and income eligible. On September 1st children turning 4 by December 1st and income eligible will be considered for enrollment if the program has openings.

Verification documentation is required to process the application.

Child's Name: Circle one: Male Female - ------------------

Name you want used at school: ___________ _ Birth date: -------

Is child Hispanic/ Latino? Yes No

Please select race (check all that apply): __ American Indian/ Alaskan Native __ Asian

Black/ African American __ White/ Caucasian __ Native American/ Pacific Islander

What language(s) is (are) spoken in the home? _____________________ _

Address: __ _ ______________ City: _________ Zip Code: ___ _ - -� I -

--li:ife1'mation about the adl(lt(s') lhe. child lives '1,'itli -�. ··; . .. ... ,,

.•.. �- .. �-2-. ,,�·

Name: Name:

What is the relationship with the child? What is the relationship with the child?

How does the child refer to this adult? How does the child refer to this adult?

Home Phone #: Home Phone #:

Cell Phone #: Cell Phone #:

E-mail Address: E-mail Address:

Employer: Employer:

Work Phone: Work Phone:

'

-- --

,,,

Plec1se circle, tl)e best me'thod te c_,ontact 't�is_ .jtc!ult. Please cir,9le the best me�hod to confijct thi_s �µult:

Who else does the child live with?

Name: _____________ Age _ _ __ Relationship to Child __________ _ Name: Age Relationship to Child ____ ___ __ _ Name: Age Relationship to Child __________ _

Who has legal custody of the child? (Verification Documentation Required)*

Name(s): ___ _____________ Relationship: __________ _ * If guardian or foster parent (other than biological parent}, please fill in the space below, as well as any

information that is known about the mother and/or father in the above boxes.

Foster Parent/ Legal Guardian (other than parent) Name: ____________ _____ _

Address: Phone Number: --------------------- ----------

Parent/ Guardian Signature: __________________ _ Date: ______ _ Return Application and Resource Request and Sharing Form and a copy of your child's birth certificate or other age eligibility documentation and proof of residence and Income Verification Form with related income documentation. Once we have all of the documents needed to determine eligibility we will let you know the likelihood of your child being accepted based on patterns of enrollment in previous years. Please know in previous years we have not been able to officially enroll children until mid-July and we expect that to be true for this coming school year as well. If you have further questions please call the

Preschool Programs office at ________ _

This material was developed under a grant awarded by the Michigan Department of Education.

Required

248-451-7770

CHILD INFORMATION RECORD

State of Michigan - Department of Licensing and Regulatory Affairs - Child Care Licensing

Instructions: Unless otherwise indicated, all requested information must be provided. If the information is not known or does not apply, "unknown" or "none" is the required response. A blank field, a line through a field or "N/A" are not acceptable responses.

:Fo

hild's Date of Birth

ddress (Number and Street, Building/Apartment Number) ity ip Code

Parent/legal Guardian's Name Home Phone Parent/Legal Guardian's Name (Optional) Home Phone

Home Address (if not child's address) Cell Phone Home Address (if not child's address) Cell Phone

ity ip Code ity ip Code

Email Address

ork Phone Employer Name ork Phone

ame of Child's Physician or Health Clinic Physician's or Health Clinic's Phone Number

ospital Preferred for Emergency Treatment (optional)

llergies, Special Needs and Special Instructions (Attach additional sheets, if necessary.)

BCAL-3731 (Rev. 7-18) Previous edition 6-17 may be used. See Reverse Side

Emergency Contact & Release of Chlld: List all individuals, including parents/legal guardians, in order of preference, to be contacted in an emergency. If possible, Include at least one person other than the parents/legal guardians to be contacted in an emergency and to whom the child can be released. The second phone number column can be left blank. (If more Individuals, attach additional sheets.)

1. ( ) ( )

2. ( ) ( )

3. ( ) ( )

Release of Chlld Only: List all individuals, other than the parents/legal guardians, to whom the child may be released. (If more individuals, attach additional sheets.)

1. ( ) 2. ( )

-

3. ( ) 4. ( )

Parent/Legal Guardian lnltlals:

___ 1 give permission to ____________ .., licensed by the Department of Licensing and Regulatory Affairs to secure emergency medical treatment for the above named minor child while In care.

I certify that I accurately completed this form and If anything changes, I will notify the provider by updating this form.

Signature of Parent or Guardian Date Signed

Date Card Parent or Legal Date Card Parent or Legal Date Card Parent or Legal Date Card Parent or Legal Reviewed Guardian Initials Reviewed Guardian Initials Reviewed Guardian Initials Reviewed Guardian Initials

AUTHORITY: 1973 PA 116

LARA is an equal opportunity employer/program. COMPLETION: Required

PENAL TY: Rule Violation Citation. BCAL-3731 (Rev. 7-18) Previous edition 6-17may be used.

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vianetdesigner

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School District of the City of Pontiac Transportation

Dear Parent and/or Guardian,

Students who are eligible to ride district buses are assigned to bus stops based on their home address. It is assumed that every student will be picked up and dropped off at this bus stop. We understand that in some cases this may not be true.

Please understand that in the interest of safety and efficiency:

• If a form is not received, the default AM/PM pickup/drop off will be based on the student's home address.

Student: ______ _______________ .School: _ ____ Grade: __ _

Home Address: ________ __ _____ ____ Phone#: _______ ___

Parent/Guardian: ____ _______________ ____ Date. ____ ___ _

TRANSPORTATION INFORMATION:

Please note when completing this section, bus stop locations must be the same for the AM (pickup) and PM (drop-off) every day. Both addresses (Home and Alternate) must be located within the attendance boundary of the student's school. Alternate address changes must be submitted to the Student Services office. The Transportation Office will require a minimum of seven (7) days to attempt to accommodate the request for change.

MY CHILD NEEDS TRANSPORTATION IN THE AM (Pickup): YES

MY CHILD NEEDS TRANSPORTATION IN THE PM (Drop-off): __ YES

__ NO (Parent drop off)

__ NO (Parent pickup)

Alternate Address: ------------------------------

Parent/Guardian Signature: _ _________________________ _

OFFICE USE ONLY: I Date Emailed to Transpottation? �-;-;::-;--;::::'. __ � Date Received I I Start Date I

Sign when complete