the registration form

South Bay
UNION
SCHOOL
Office Use Only
DISTRICT
(To be completed by parent/guardian)
SSID No: __________________
DOR: _____________________
6077 Loma Avenue • Eureka, California 95503
NAME OF SCHOOL:______________________________________
ANTICIPATED START DATE:______________________________
Teacher: __________________________________
Student’s LEGAL Name:____________________________________________________ Date of Birth: _______________________
(from birth certificate)
Last Name
Last Name Mother Step Mother
First Name
Middle Name
Mo/Day/Year
]] ()
Guardian First Name Home Phone
] ()
Male
Female
Cell/Work Phone
Mailing Address
City
State
ZIP
Residence Address (IF DIFFERENT)
City
State
ZIP
E-mail Address
Last Name Father Step Father
]] ()
Guardian
First Name Home Phone
] ()
Cell/Work Phone
Mailing Address
City
State
ZIP
Residence Address (IF DIFFERENT)
City
State
ZIP
E-mail Address
DUPLICATE MAILING — If divorced/separated & joint custody allows duplicate mailing/information to be given to other parent, please include their name,
address and phone number.
Last Name/Relationship to student
]] ()
First Name Home Phone
] ()
Mailing Address
City
Last School Attended: Name of School City/State
State
Yes
ZIP
Last Date of Attendance: Phone No.
MEDICAL INFORMATION — Are there medical issues that the school should be aware of?
Cell/Work Phone
No
If yes, please describe: Medication taken at home? Yes
No
If yes, please describe: Medication taken at school? Yes
No
If yes, please submit the Medication Form signed by doctor at time of registration.
Allergies the school should be aware of? Yes
No
If yes, please describe: Has the student been expelled or is the student in the process of being expelled from any school?
If yes, name of school: Student Birthplace: Yes
Location: No
Date Expelled: If not born in the U.S. what month/year did your child enter U.S.?
City/State/Country What month and year did your child first enroll in a U.S. School?
/
In a California School?
/
Mo./Year
/
What special services has your child received? (Please check all boxes that apply)
Special Education:
Other:
Resources (RSP)
Gifted (GATE)
English Lang. Dev.
Special Day Class
Remedial Math
Medical Health Plan
Page 1 of 2
Speech/Language
Remedial Reading
504 Accommodation Plan
Counseling
HOME LANGUAGE SURVEY
Which language did your son/daughter learn when he/she first began to talk? What language does your son/daughter most frequently use at home? What language do you use most frequently to speak to your son/daughter? Name the language most often spoken by adults at home: ETHNICITY: Mark the ethnicity with which the student most closely identifies. Please check one:
Must answer both questions
Hispanic/Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race)
Non Hispanic or Latino
WHAT IS YOUR CHILD’S RACE? (Please check up to five racial categories) The above part of the question is about ethnicity, not race. No matter
what you selected above, please continue to answer the following by marking one or more boxes to indicate what you consider your race to be.
American Indian or Alaskan Native (100)
(Person having origins in any of the
original peoples of North and South
America (including Central America)
Chinese (201)
Japanese (202)
Korean (203)
Vietnamese (204)
Asian Indian (205)
Laotian (206)
Cambodian (207)
Hmong (208)
Other Asian (299)
Hawaiian (301)
Guamanian (302)
Samoan (303)
Tahitian (304)
Other Pacific Islander (399)
African American or Black (600)
White (700)
(Persons having origins in any of the
original peoples of Europe, North
Africa, or the Middle East)
RESIDENCE ­— Where is your child’s family currently living? (Federally mandated by NCLB: Please check appropriate box)
In a single family permanent residence (house, apartment, condo, mobile home)
Double-up (sharing housing with other families/individuals due to economic
hardship, loss or other reasons)
In a sheltered or transitional housing program
In a motel/hotel
Unsheltered (car/campsite)
Foster/Group Home
Other ___________________________________________________
OTHER CHILDREN IN THE FAMILY:
First and Last Name
Relationship
Lives at Home
School
Grade
(If graduated, not applicable)
________________________________ ________________________ Yes
No
____________________________ _______________________
________________________________ ________________________ Yes
No
____________________________ _______________________
________________________________ ________________________ Yes
No
____________________________ _______________________
OTHER ADULTS IN THE HOME:
___________________________________ __________________________ _____________________________________ __________________________
Name
RelationshipName
Relationship
PARENT EDUCATION LEVEL: Check the response that describes the highest education level of parent/guardian(s).
Not a high school graduate
High school graduate
Some college (includes AA degree)
College Graduate
Graduate school/post graduate training
I/We have reviewed this two page document and to the best of my/our knowledge, the information contained herein is true and
complete. The undersigned declares under penalty of perjury that they are the parents or legal guardians of the above-named student and
grant the above authorizations.
Date: ______________________
Signature of Parent/Guardian: ______________________________________________
BELOW FOR SCHOOL USE ONLY
Proof of Birth:
Type: __________
Verified by: _____
Proof of Residence:
Type: ___________
Verified by: ______
Proof of Immunizations: Enrollment Date
Type: ____________
Verified by: _______
Page 2 of 2
Teacher/Class
Assignment
PROMIS/SEIS
Completed
Class list complete
201304/South Bay/School Registration Documents/SB School Registration
SOUTH BAY UNION SCHOOL DISTRICT
Parent Authorization for Release of School Records from:
________________________________________________
(NAME OF SCHOOL)
_______South Bay School (4-8)
6077 Loma Ave.
Eureka, CA 95503
________________________________________________
(ADDRESS OF SCHOOL)
_______Pine Hill School (K-3)
5230 Vance Ave.
Eureka, CA 95503
In accordance with the Family Educational Rights and Privacy Act of 1974 and
California State Law, I hereby authorize the release to the school named above of all
records, including grades and health records, as well as psychological, social,
educational, or developmental information (including confidential information
relevant to the Special Education Master Plan) regarding the following pupil/pupils:
___________________________________________Birthdate______________Entering Grade________
___________________________________________Birthdate______________Entering Grade________
___________________________________________Birthdate______________Entering Grade________
___________________________________________Birthdate______________Entering Grade________
Parent /Guardian
Signature________________________________________Date___________________
DIRECTORY RELEASE REFUSAL FORM
Dear Parent/Guardian
South Bay School District is proud of the many accomplishments of our
students and staff. Often, such accomplishments draw the attention of
newspapers, television stations, or other media who visit our schools to
photograph, film and/or interview students and staff during various activities.
In addition, we often use pictures of our students in South Bay School
District publications and web pages. For our protection and that of your
child’s privacy, we must know if you DO NOT want your child to be
photographed, filmed or interviewed by the news media or for South Bay
School District publications and web pages.
I DO/DO NOT (circle one) want my child’s image or words used by the
news media or South Bay School District for various publications and web
pages.
If you do not indicate your preference above, we will assume you have given
permission for your child to be photographed, filmed or interviewed during
school and classroom activities by members of the news media, and for your
child’s photograph and/or words to be used in South Bay School publications
and web pages.
Note: This form does not include classroom displays or yearbook photos. If
you do not want your child in a yearbook, contact your child’s principal.
Student Name______________________________________
Parent Name_______________________________________
Date________________________________________________