WATTSBURG AREA SCHOOL DISTRICT STUDENT ... Registration.pdfHOME LANGUAGE SURVEY ALL newly...
9
WATTSBURG AREA SCHOOL DISTCT STUDENT REGISTRATION FO Grade Entering ___ __ __ _ WAS D School Ente ng _______________ To d ay ' s D ate _____ __ _ STUDENT OTION Child' s Full ga !Nam e _ _ �- - ��-------------� -- -- Disct # ____ _ _ _ _ t (List gon: Sr., Jr., , Bir Date _ ___ ____ _ _ _ D Male □Female Fst Mid Date entered P A school Disct e oy If non-resident, Home Disct ________________________ _ ____ __ ________ _ DISCT USE OY Residency Co d e _ _____ _ Cucul Code __ _____ _ Home Room# _____ _ Eny Date Eny Code Locker#- - -� -- PA S ecure ______ _ Registered wi previous school records? _ _ Yes __ No ation? _ _ Yes _ _ No Records sent r ? _ _ Yes _ _ No P household pent(s) that school foation is to be sent to: _ ____ __ _ _ _ _ _ _ Relaonship _______ _ _ Name that e child prers to be cled in schoo l ____________ _ __________ _________ _ _ Chi l d's e-m adss (That he/she h ac c ess to) _ _ ____ _____ ______________ _____ _ Name of previous school aended _ _ _________________ _ _______ _ _______ __ _ _ Locaon of previous school (List ci d s te),_ ___ ___________________ _________ _ _ Highest ade completed _ _____ __ Has he/she ever been t a ined? 0Yes 0No If yes, list ade __ _______ _ Did e child receive y type of speci educaon services or remeaon in the previous school? (Inclug Giſted p r oams) D Yes D No FOR GES 6, 7, 8 ONLY-wodyourcd liketo be schedr Band Yes D No or Chorus? OYes ONo (The child must already play i n se n t to sign up r bd.) JOT CUSTODY PENT ORMATION f Joint Custody and/or chd does not re side full time Please complete inrmatio n below) Father's Ne _ _______ __ ________ _ _______ ___ _______ _ ________ _ M a i l ing A ddress ______ _ _ _________________________ _ __________ _ (Seet or PO Box) City State Zip Code Home Phon e ___________ _ __ C ell P hone ____________ W o P ho n e ___________ _ E m a i l Add r ess __ _ ________ __ _____ ___ _ _________________ _ _____ _ M other's Ne _____ __ _______ _ _______ ___ _ _______ _ __ ____ __ _ _ _ M a il ing A d ess _ ________________________________________ _ (St or PO Box) City State Zip Code H o m e Phone _________ _ ____ Cel l P hone ____________ W o rk P h o n e ___________ _ E m ai l A ddress ___________________________________ ______ _ _ __ _ • If the child does not reside w i both biological parents, d ocu m entation is requed to restct the shing of educational inrmation with e oer pent • If you e e guardi of the child, diship pers e required d must be updated nual l y. CASE OF SERIOUS ACCIDENT OR LNESS Please list twoother persons e school m ay call r adv i ce or direction cing r your child in case of serious accident, illness or disaster wing. (If parent/ardia n cannot bereached, the school use these contacts.) Name Relationship to child Home P h one Cell Phone Wor k Phone Name Relationship to child Home Phone Cell Phone Work Phone Name Relationsp to c l d Home Phone C ell Phone Wo Phone Revised M⌒h 2016 I
Transcript of WATTSBURG AREA SCHOOL DISTRICT STUDENT ... Registration.pdfHOME LANGUAGE SURVEY ALL newly...
WATTSBURG AREA SCHOOL DISTRICT
STUDENT REGISTRATION FORM
Grade Entering _______ _ WASD School Entering _______________ Today's Date _______ _STUDENT INFORMATIONChild's Full Lega!Name __ �--��-------------�--- District ID# _______ _
Last (List generation: Sr., Jr., II, III) Birth Date __________ _D Male □Female
First MiddleDate entered PA school
District use only
If non-resident, Home District _______________________________________ _
DISTRICT USE ONLYResidency Code _______ Curriculum Code ________ Home Room# _____ _Entry Date Entry Code Locker#---�-- PA Secure!D ______ _Registered with previous school records? __ Yes __ No Immunization? _ _ Yes __ No Records sent for? __ Yes __ No
Primary household parent(s) that school information is to be sent to: _____________ Relationship ________ _Name that the child prefers to be called in school _________________________________ _Child's e-mail address (That he/she has access to) ______________________________ _Name of previous school attended ______________________________________ _Location of previous school (List city and state), _________________________________ _Highest grade completed ________ Has he/she ever been retained? 0Yes 0No If yes, list grade _________ _Did the child receive any type of special education services or remediation in the previous school? (Including Gifted programs) D Yes D No
FOR GRADES 6, 7, 8 ONLY-wouldyourcbild liketo be scheduled for Band lJYes D No or Chorus? OYes ONo(The child must already play an instrument to sign up for band.)
JOINT CUSTODY PARENT INFORMATION (If Joint Custody and/or child does not re side full time Please complete informatio n below)Father's Name _____________________________________________ _Mailing Address ____________________________________________ _
(Street or PO Box) City State Zip CodeHome Phone ______________ Cell Phone ____________ Work Phone ___________ _Email Address _____________________________________________ _Mother's Name ____________________________________________ _Mailing Address _________________________________________ _
(Street or PO Box) City State Zip CodeHome Phone ______________ Cell Phone ____________ WorkPhone ___________ _Email Address _____________________________________________ _
• If the child does not reside with both biological parents, documentation is required to restrict the sharing of educational information withthe other parent
• If you are the guardian of the child, guardianship papers are required and must be updated annually.
IN CASE OF SERIOUS ACCIDENT OR ILLNESSPlease list two other persons the school may call for advice or direction in caring for your child in case of serious accident, illness or disasterwarning. (If parent/guardia n cannot be reached, the school will use these contacts.)Name Relationship to childHome Phone Cell Phone Work PhoneName Relationship to childHome Phone Cell Phone Work PhoneName Relationship to childHome Phone Cell Phone Work Phone
Revised March 2016 I
WATTSBURG AREA SCHOOL DISTRICT
FAMILY INFORMATION FORM
Head ofHousehold Name _____________________________ ,District ID# ________ _ Last (List generation: Sr,, Jr., IT, III) First District use only
Street Address _____________________________________________ _ House Number & Road, Lot or Apt. # City State Zip Code
Mailing Address _________________________________________ _ If different from above (PO Box) City State Zip Code
Home Phone Number ____________ Och eek if Private and/or Not Listed Township ___________ _
HEAD OF HOUSEHOLD'S INFORMATION
Relationship to child(ren) in household ____________________________________ _ E-Mail address, __________________________ Cell Phone No. _____________ _Place ofEmployment Work Phone No. ____________ _
OTHER ADULTS LIVINGS IN HOUSEHOLD (at above address)
(1) Head of Household Name, _________________________ District ID# ________ _Last (List generation: Sr., Jr., IT, III) First District use only
Relationship to child(ren) in household _________________________________ _E-Mail address, _______________________ Cell Phone No. _____________ _Place of Employment Work Phone No. ____________ _
(2) Head of Household Name. _______________________ District ID# _______ _Last (List generation: Sr., Jr., JI, ID) First District use only
Relationship to child(ren) in household _________________________________ _E-Mail address, ______________________ _ Place of Employment ___________________ _
CIDLDREN LIVING IN HOUSEHOLD (at above address)
Cell Phone No. ____________ _WorkPhoneNo. ____________ _
(I) Name _______________________________________ _Last (List generation: Sr., Jr., II, III) First Middle
Birth Date Male □ FemaleO Grade/Age School
(2) NameLast (List generation: Sr., Jr., II, III) First Middle
Birth Date Male D Female□ Grade/Age School
(3) NameLast (List generation: Sr., Jr., II, III) First
Birth Date Male D Female Oorade/Age School Middle
(4) NameLast (List generation: Sr., Jr., II, ill) First Middle
Birth Date MaleD Female D Grade/Age School
(5) NameLast (List generation: Sr., Jr., II, ill) First Middle
Birth Date MaleQ_FemaleQ_Grade/Age School
Revised March 2016 2
Child's Full Name. __ ....,..-,,-,---,--....,........,........,....=-------=-----�District ID# _____ _ Last (List generation: Sr., Jr., II, ill) First District use only
PLEASE ANSWER THE FOLLOWING QUESTIONS:
Is this student Hispanic/Latino? (Choose only one)
D No, Not Hispanic/Latino
D Yes, Hispanic/Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin, regardless of race.)
What is the student's race? (Choose one or more)
D American Indian or Alaska Native(A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment.)
D Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian 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 original peoples 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 North Africa.)
If this information is not provided, the district is required to fill it out by observation.
District observation used
Revised March 2016 3
� pennsylvania u DEPARTMENT OF EDUCATION
HOME LANGUAGE SURVEY
ALL newly registering students regardless of race, nationality, or language origin MUST complete this
form. Federal law requires that all Local Education Agencies (LEAs) utilize a non-biased procedure for identifying which students are potential English Learners (Els) in order to provide appropriate language instruction educational programs and services. Given this responsibility, LEAs have the right to ask for the information contained on this and other forms associated with the identification process.
Student Information (Parents/Guardians should complete this section):
Child's first name: __________________________ _
Child's family name: _________________________ _
Child's Date of Birth: _________________________ _
(Month/Day/Year)
Questions for Parents or Guardians
1. Is a language other than English spoken in the child's home? D No D Yes (language) _____ _
2. Does your child communicate in a language other than English'[] No D Yes (language)-------
3. What is the language that your child first learned to speak? -----------------
Parent/Guardian Signature: __________________ Date: ________ _
Interpreter Provided D No Oves
Revised February 2017
:/\Sr.> WATTSBURG AREAl 0782 Wattsburg Roa.dErie, PA 16509
Mrs. Rebecca Kelley Assistant to the Superintendent
S O IS RI ST!JOENT CHITE!IECHUTUR6 FOCUSHJ
Mr, Kenneth A. Berlin Superintendent
PARENTAL REGISTRATION STATEMENT
P (814) 824-3400F (814) 824-5200www.wattsburg.org
Mrs. Vicki L. Bendig Business Administrator
Student Name __________________________________ _
Date of Birth _____________ Grade __ _
Parent or Guardian Name ______________________________ _
Address ____________________________________ _
Home Phone No. ______________ Cell Phone No. _____________ _
Pennsylvania School Code #13-1304-A states in part "Prior to admission to any school entity, the parent, guardian or other person having control or charge of a student shall, upon registration, provide a sworn statement or affirmation stating whether the pupil was previously suspended or expelled from any public or private school of this Commonwealth or any other state for an act of offense involving weapons, alcohol, or drugs, or for the willful infliction of injury to another person or for any act of violence committed on school property."
Please complete the following:
I hereby swear or affirm that my child was D was notO previously suspended or expelled from any public orprivate school of this Commonwealth or any other state for an act of offense involving weapons, alcohol, or drugs, or for the willful infliction of injury to another person or for any act of violence committed on school property.* I make this statement subject to the penalties of24P.S.#13-1304-A(b) and 18 Pa. CSA. #4904, relating to unsworn falsification to authorities, and the facts contained herein are true and correct to the best of my knowledge, inforruation and belief.
(Signature of Parent or Guardian)
(Signature of Student, High School Only)
(Date)
*Name of school from which student was suspended or expelled; reason for suspension/expulsion; and dates ofsuspension or expulsion ( optional).
Any willful false statement made above shall be a misdemeanor of the third degree. This form shall be maintained as part of the student's disciplinary record.
Revised 07.09.2019 5
CH OLD T CT
Mr; Christopher Paris Principal
Wattsburg Area Middle School 10774 Wattsburg Road
Erie, PA 16509 (814) 824-3400
www.wattsburg.org
Mrs. Krista Wehan Assistant Principal
AUTHORIZATION FOR RELEASE OF INFORMATION
I hereby request that pertinent scholastic records, test scores, psychological information, special education records, medical information and discipline records concerning:
Student's name _____________________________ _
Birth date _______________ Grade ____ _
be released to: Wattsburg Area School District Wattsburg Area Middle School 10774 Wattsburg Road Erie, PA 16509
Releasing/Previous School _________________________ _
Mailing Address _________________________ _
City, State, Zip __________________________ _
Parent'Guardian Signature
Date
This student has enrolled in our school. In accordance with Section 1305-A of Pennsylvania Act 26 of 1995, we request that a certified copy oftbis student's discipline record be sent to us within the IO-day guideline.
If applicable, please send the PA State ID number for this student with their other records.
R . dd'Y1i9'fln<;Jiallenges all students with rigorous, differentiated instruction provided by a caring staff.6 evtSe · ·
An Equal Rights and Opportunity School District
~ WATTSBURG AREA SCHOOL DISTRICT
STUDENT CENTERED·FUTURE FOCUSED
WATTSBURG AREA SCHOOL DISTRICT TRANSPORTATION DEPARTMENT
School Enrollment Date _______ _
List all children that will need W ASD transportation at this location.
Name ______________ Grade __ School Attending ________ _
Name _____________ Grade __ School Attending ________ _
Name ______________ Grade __ School Attending ________ _
Name ______________ Grade __ School Attending ________ _
Name ______________ Grade __ School Attending ________ _
LOCATION OF RESIDENCE
Street Address ______________________________ _ House Number and Road, Lot Number
Between what two roads? ____________________________ _
Color of house ________________________________ _
If you are a working parent during school hours and need bus transportation for your child(ren) from or to a regular alternate stop before or after school, please complete the following: (This request must be approved by the Transportation Department. They will notify you if your request has been approved.)
Alternate Pickup (a.m.) ___________________________ _ House Number and Road, Lot Number
Adult Contact at Alternate Pick-up ____________ Phone Number _______ _
Alternate Drop-off (p.m.) _________________________ _ House Number and Road, Lot Number
Adult Contact at Alternate Pick-up ___________ Phone Number ______ _
FOR DISTRICT USE ONLY
Morning Pick-up Time _______ _
Afternoon Drop-off Time ______ _
Morning Pick-up Time _______ _
Afternoon Drop-off Time ______ _
Morning Pick-up Time _______ _
Afternoon Drop-off Time ______ _
Revised March 2016
Seneca/Middle School Students
Seneca/Middle School Students
Elementary Center Students
Elementary Center Students
Other School
Other School
7
---------- ~---------- -------------------------- --------- --------------
To Parents or Guardian:
WATTSBURG AREA SCHOOL DISTRICT HEALTH HISTORY
The information requested on this form will help the school authorities in determining the health status of your child and in assisting him/her to received maximum benefits from his/her educational opportunity.
Child's Full Legal Name _________________________ _
BirthDate _________ Place ofBirth(city), ______________ _
HEAL TH IDS TORY (Please give dates and details where known)
Asthma _________________________________ _ Allergy _________________________________ _ Bee Allergy (Severe) ____________________________ _ Chicken Pox _______________________________ _ Diabetes ________________________________ _ Epilepsy ________________________________ _ 0peration(type) ____________________________ _ Serious Accidents _____________________________ _ Tuberculosis- self _____________________________ _ Tuberculosis - family ____________________________ _ Cardiac problems _____________________________ _ Emotional problems ____________________________ _ Gastrointestinal problems __________________________ _ Kidney/Bladder problems _________________________ _ Recurrent illness _____________________________ _ Other _________________________________ _ Has your child ever been hospitalized? Please give date(s) and reason(s).
Is your child under medical treatment at the present time? D Yes D No Name of Physician: ____________________________ _ Reason:---------------------------------Is your child on any medication(s)? _______________________ _Does your child wear glasses? D YesONo Please list any eye problems: _________________________ _
Revised March 2016
8
Please list any hearing problems your child may have---�-------------
Does your child have any medical conditions that could affect their ability to succeed in school?
Name offamily physician: _____________ Phone number _______ _
Name offamily dentist: ______________ Phone number _______ _
Preferred hospital for emergency treatment: ____________________ _
Is your child covered by medical insurance? ____________________ _
SIGNATURE OF PARENT OR GUARDIAN ___________ Date ____ _
For WAMS and SHS students only!
Please sign below if your child is permitted to be given, at the nurse's discretion, non-aspirin pain medication during the school day.
Signature of Parent or Guardian
Please sign below if the above medical and health information can be shared with your child's teachers, bus drivers, coaches, and other school staff as deemed necessary to best provide for your child while in school.
Signature of Parent or Guardian
Revised March 2016 9
