REGISTRATION BY APPOINTMENT ONLY:  PLEASE CALL 419-824-8581
STUDENT INFORMATION FORM
School: 						   	School Year: 		2017-2018		
Student ID # 						Grade 						
Student Information							
Legal Last Name 						Address	 					
Legal First Name _________________________________		Apt# 			   Lot # 			
Middle Name	 					City 						
Date of Birth 			 Age 			State 			Zip Code 		
Gender (Circle)		Male		Female		Phone No. 					
Legal District (If court placed) 				Siblings in District:  Yes 		      No 		
Miscellaneous
Birth City 						Birth State 					
Birth Country 						Citizen of 					
Native (First) Language 					Main Language Spoken at Home 			
Is the student Hispanic/Latino? _____ Yes  ______ No
Ethnic Description: Please circle all that apply:         A- Asian            W- White             B- Black/African American       
				              	I- American Indian /Alaskan Native        P- Native Hawaiian/Pacific Islander
Disability Services/504 Information					
If your child is receiving special education or 504 services please complete this section. Check all that apply.
Current IEP 			Current Evaluation 			(Include Speech Only Services)
504 Plan 			Checked documents must be presented at the time of registration.
Previous School District
School  							Phone No. 					
Address 							Fax No. 						
							District Name 					
If the student was not born in the United States, please answer the following:
Is this the first time attending a school in the United States?		Yes 		No 	
If  No, how long has the student attended a school in the United States?  (Months and/or Years)					
Parent/Guardian Information	
1. Name 							2. Name						     
    Relationship 						    Relationship 					
    Living with student:  Yes 		   No 			    Living with student:  Yes 		  No 		
    Address if different: 					    Address if different 				
    							     						
    Can Pick Up Student:   Yes 	   No 			    Can Pick Up Student:   Yes 	   No 		
    Emergency Call Priority:  No. 1 	        No. 2	  	    Emergency Call Priority:  No. 1 	        No. 2	
    Employer 						     Employer 					
    Occupation  						     Occupation 					
    Work Phone 			Ext. 			     Work Phone 			Ext. 		
    Cell Phone 						     Cell Phone 					
    E-mail  						      E-mail 					
Custody Information- **File Stamped Court Documents must be presented at the time of registration.
Parents legally- separated 	____   divorced ___________  in process with Court papers 	______   never married 		 
Do Court papers indicate joint custody/shared parenting?	_________ Yes		_________ No
Who has primary residential custody per court Records?	_________Mother	__________Father 	__________Guardian
			
Emergency Contacts (Other than Parent/Guardian Listed on first page) 
Last Name							Last Name					
First Name 							First Name					
Relationship 							Relationship					
Can pick up student:	Yes 		    No 	    	 	Can Pick Up Student:    Yes 		No	
Emergency Call Priority:	No. 3 	   	    No. 4 	       		Emergency Call Priority: No. 3                 No. 4          	
Address								Address	     					
							  	    		 				
Home Phone							Home Phone 	 				
Work Phone							Work Phone	 				
Cell Phone							Cell Phone	 				

Medical
Doctor’s Name							Dentist’s Name 					
Address								Address	        					
Phone								Phone             					

Preferred Hospital 						Phone 						
Health Ins/Medicare 					
Allergies 													
Are allergies life threatening?	Yes	No	Other 								
Health Factors 													

School –Age Sibling Information
Name	1. 				   2. 					  3. 				
Relation	 				       					      				
School	 				       					      				
Grade					       					      				

(If you need additional space for school-age siblings, please list on the back of page.)

All information listed on the verification form is accurate for enrollment purposes.

													
Parent Signature							Date

Sylvania Schools – Residency Affidavit

Name of Student: 							 School: 				

	According to Ohio Revised Code, school districts have the right to request verification of legal residency.  By signing this affidavit, you are affirming that the address given on the student enrollment form(s) is the legal residence of the parent/guardian enrolling the student and the legal residence of said student.  You must also provide the proper documentation to prove your residency in the district.

	Further, I am aware of the Policy of the Sylvania School District, which states that if a student is found to have residency in our district by using false or inaccurate information, the student will be dismissed/excluded from school until resolved by school Administration.  If determination is made that there was an attempt on the parent/student/or resident to defraud the Sylvania School District, restitution will be sought legally.  Sylvania Schools may file charges with local authorities to prosecute and recover reimbursement for tuition and legal fees from the parties responsible.  Those responsible will be held liable for all costs incurred while the student was enrolled in the Sylvania School District.  The tuition rate will be based on the daily rate for the current school year.

By signing below, you indicate that you have read and understand this document.

															
Signature of Parent/Guardian						Date

														
Signature of Person with whom residing (if applicable)			Date

								(Office Use Only):
New Phone Number (if applicable) ________________________						                              											New Student ___________
					                                       			     Parental Move__________
Sylvania Schools – Verification of Residency

Name of Student: 							 School: 				

Please fill in and sign the appropriate section(s).  School official will attach a copy of the proof of residency to this form.

SECTION A: Please check one:

	I reside with my child at 											
	I have supplied school officials with proof of residency.
	I have purchased a home at 										
I will be residing with my child at this address within 60 calendar days of the child's first date of attendance.  I have supplied school officials with a copy of the purchase contract.
	I am building a home at 											
I will be residing with my child within 90 calendar days of the child’s first date of attendance.  I have supplied school officials with a signed contract from the builder.

									 					
Signature of Parent/Guardian							Date

SECTION B for Foster Parents or Guardians

I am the Foster Parent or Legal Guardian of 								.  This child is presently residing in my residence at 								 on a full-time basis.  I have supplied school officials with court documents verifying the custody order.

Signature of Foster Parent or Guardian						Date
Section C – Statement of Domicile

I, 									 declare that 				
		District Resident									Student
physically resides in my home at 										 

on a full-time basis with 						.  They have NO other residence listed on 
				Parent/Guardian
documents, and further declare that they eat, sleep, and maintain daily activities at this residence.

									 					
Signature of Person Providing Residence					Date

___________________________________________________________
Phone Number of District Resident

Signature of Notary 							 Notary Phone # 		

Office of Student Services
Robert Verhelst, Director

REQUEST FOR TRANSFER OF SCHOOL RECORDS

This form is provided by the Sylvania Schools for the purpose of obtaining or releasing a student’s school records.  By signing this release, a parent, legal guardian, or the student involved who is over 18 years of age, will expedite the transfer of records to another school for enrollment in that school.
Please include test scores, social, psychological, academic and health records.

Release Records To:		Sylvania Schools Student Services
			Attn: Hema Shah
					4747 N. Holland Sylvania Rd.
					Sylvania, OH 43560
					hshah@sylvaniaschools.org

								DATE OF
NAME OF STUDENT 						 BIRTH 			 GRADE 	

NAME OF SCHOOL
STUDENT IS LEAVING 											

ADDRESS OF SCHOOL 											
City _____________________ State___________ Zip___________ FAX: ___________________
I hereby authorize the transfer of school records for the above named student.  By signing this request for transfer, I relieve the school which the above named student was attending of the responsibility of notifying me that the records are being transferred.

Date 			 Signature									
			 (Parent, Legal Guardian, or self if 18 years of age)
			Address 									
			(If moving, list new address if available)
Date 			 Signature 									
			 (Name and title of school person initialing request for transfer)
Name of school the student will be attending in Sylvania _______________________________
1.	Parents, Legal Guardians or legal age students may request review and/or copy of the records transferred.  If you request a copy of the school records being transferred, the school is relieved of responsibility for confidentiality of those records.
2.	Records transferred by this release are not to be transferred to any other third party by the receiving school without the written consent of the parent, legal guardian, or student over 18 years of age.	

Information/records needed for enrollment:
1. 	 Copy of current grades/transcript of past grades.
2. 	 Standardized test results.
3. 	 Copy of health record/immunization dates
4. 	 Copy of attendance/suspension/discipline records
5. 	 Copy of current evaluation – current IEP – current 504 Plan
6. 	 Birth Certificate.
7. 	 Custody papers		
	                                                               PLEASE DO NOT FAX RECORDS 

Office of Student Services
Robert Verhelst, Director

Student Registration
Home Language Survey

Student Name	_________________   __________________  ________________  ______________
                             First Name	                Middle Name              Last Name                Called Name

Birth Date: __________________       Gender  _________   Grade  _____________

Place of Birth: __________________  _________________  _________________
                                  City		 State		             Country
                         
Parent/Guardian __________________  Address  _______________________________________
                                                                                                             City                State             Zip Code

Home Phone  ____________  Work Phone  ______________  Cell  _____________

 What language did your son/daughter speak when he/she first learned to talk? ____________________

What language does your son/daughter use most frequently at home?  __________________________

What language do you use most frequently with your son/daughter:  ____________________________

What language do the adults at home most often speak?  ____________________________________

Does anyone in your home read English?     Yes _____    No  _____

Is the student from a foreign country?        Yes  ______  No  ______
   If yes, please answer the following questions:

       Date of entry into USA:______________ Country of origin:  _________________

 When did your son/daughter first enroll in school in the US?  Month  ________ Year  ________

_________________________________________      _______________
(Signature of Parent or Guardian)				  Date