Student Enrollment Form

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Kahrs – Revision 07/23/2014

Student Enrollment Form

S

TUDENT

N

AME

(M

UST

M

ATCH

B

IRTH

C

ERTIFICATE

)

Student Last Name Student First Name Student Middle Name Student’s Preferred Name

P

REVIOUS

S

CHOOL

E

NROLLMENT

Has the Student Ever Been Enrolled in Cleveland City

Schools Before?

 Yes

 No If Yes, When/Where? Does the Student Have

Siblings Already Enrolled in Cleveland City Schools?

 Yes  No

If Yes, Please List Their Names/Schools. Has the Student Ever Been

Enrolled in a Tennessee Public School?

 Yes

 No If Yes, When/Where? If Not Already Listed

Above, Please List the Student’s Last School Name, City, and State

S

TUDENT

D

EMOGRAPHICS

Gender  Male  Female Birthdate

Grade Level Social Security Number

Did Student Receive Special Services at Previous

School?

 Yes

 No List Any Legal Alerts to be Included in Student’s File

B

IRTH

I

NFORMATION

(R

EQUIRED BY

S

TATE OF

T

ENNESSEE

)

Mother’s Maiden Name

Student’s Birth City Student’s Birth County

Student’s Birth State Student’s Birth Country

R

ESIDENCY

I

NFORMATION

(R

EQUIRED BY

S

TATE OF

T

ENNESSEE

)

Where does your student stay at

night?

 Home/Apartment Owned/Rented by Parent/Guardian  Shelter  Campsite  With Relative/Friend (Family Does Not Have a Residence)  Motel  Automobile

 Inadequate Housing (No Electricity/Running Water)  Other (Explain):

For Office Use Only ___ Birth Cert ___ Immunization ___ Soc Sec Card ___ Custody ___ Proof of Address

___ Withdrawal/Report Card AM Bus: ____ PM Bus: ____

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O

THER

S

TUDENT

I

NFORMATION

Student’s Primary Phone # Student’s Email Address Student’s Primary Physical Address

Zoning for this Address  In Zone  Out of Zone  CCS Employee Will Student Ride Bus?  AM  PM  Both  Will Not Ride List Any Medical Alerts to be

Included in Student’s File

Student’s Ethnicity  Latino/Hispanic  Not Latino/Hispanic Student’s Race

(Check All That Apply)

 American Indian or Alaskan Native  Asian  Black or African American  Native Hawaiian or Pacific Islander  White

P

RIMARY

S

TUDENT

C

ONTACT

(A

DDITIONAL

C

ONTACTS

S

HOULD

B

E

A

DDED

T

HROUGH

P

ARENT

C

ONNECT

XP)

Primary Contact Name Relationship to Student

Lives with Student?  Yes  No

Custody (  Primary or  Joint) of Student?  Yes  No

Contact for Student Emergency?  Yes  No

Can Pick Up Student?  Yes  No

Email Address (  Send Automated Messages/Notifications) Primary Phone Number (  Send Automated Messages/Notifications)

Cell Phone Number (  Send Automated Messages/Notifications) Work Phone Number (  Send Automated Messages/Notifications)

Contact’s Address

 Same As Student (Do Not Fill Out)

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Contact Form for Parents

without Internet Access

Once a primary contact is entered into the CCS Data System and processes overnight, that parent may then log into ParentConnectXP and add/edit additional contacts and their access to the student(s). Please contact your student’s school for information on logging in to the ParentConnectXP system.

Arnold Elementary, (423) 472-2241 Blythe/Bower Elementary, (423) 479-5121

Cleveland High School, (423) 478-1113 Cleveland Middle School, (423) 479-9641 Mayfield Elementary School, (423) 472-4541

Ross Elementary School, (423) 479-7274 Stuart Elementary School, (423) 476-8246

Teen Learning Center, (423) 339-0902 Yates Primary School, (423) 479-1723 If a parent does not have access to a computer with Internet access, you may fill out the form below and return it to your child’s school. If a child has siblings in other Cleveland City schools, only one form is need to update all records.

S

TUDENT

I

NFORMATION

Student Name Primary Contact Name

Siblings in CCS (with school in parentheses)

A

DDITIONAL

C

ONTACT

#1

Contact’s Address  Same As Student

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A

DDITIONAL

C

ONTACT

#2

A

DDITIONAL

C

ONTACT

#3

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Home Language Survey

E

NGLISH

Student Name School

Students whose native language is NOT English will be tested for inclusion in the ESL Program. What is the First Language Your Child Learned to Speak?

What Language Does Your Child Speak Most Often Outside of School?

What Language do People Usually Speak in Your Child’s Home?

Was the Student Born in the U.S.? _{ No (Answer Remaining Questions)} Yes (Skip Remaining Questions)

Is the Student a U.S. Citizen?  Yes  No

When Did the Student Enter the U.S.? When Did the Student Start School in the U.S.?

E

SPAÑOL

Nombre del Alumno Escuela

Se evaluarán a los estudiantes que no tengan inglés como su idioma primaria para inclusión en el programa de ESL. ¿Cuál es la primera lengua que su niño aprendió a hablar?

¿Cuál lengua habla su niño más frecuentemente afuera de la escuela?

¿Cuál lengua hablan la gente generalmente en la casa de su niños?

¿Nació su niño en Estados Unidos? _{ No (Responda a las preguntas que quedan)} Si (No responder las preguntas restantes) ¿Es el estudiante un ciudadano de Estados Unidos?  Si  No

¿Cúando entró el estudiante en Estados Unidos? ¿Cuándo el estudiante comenzar la escuela en los Estados

Unidos?

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Student Records Request

S

CHOOL

R

EQUESTING

R

ECORDS



Arnold Elementary School

Mr. Mike Chai, Principal 473 8th_{Street NW} Cleveland, TN 37311 Voice: (423) 472-2241 Fax: (423) 472-9877



Blythe/Bower Elementary School Dr. Joel Barnes, Principal

604 20th _{Street SE} Cleveland, TN 37311 Voice: (423) 479-5121 Fax: (423) 472-2459



Cleveland High School

Mrs. Autumn O’Bryan, Principal 850 Raider Drive NW

Cleveland, TN 37312 Voice: (423) 476-1832 Fax: (423) 478-5865



Cleveland Middle School Mr. Mike Collier, Principal 3635 Georgetown Road NW Cleveland, TN 37312 Voice: (423) 479-9641 Fax: (423) 479-9553



Mayfield Elementary School Mr. Kelly Kiser, Principal 501 20th_{Street NE} Cleveland, TN 37312 Voice: (423) 472-4541 Fax: (423) 472-2539



Ross Elementary School Mrs. Lisa Earby, Principal 4340 Mouse Creek RD NW Cleveland, TN 37312 Voice: (423) 479-7274 Fax: (423) 472-9763



Stuart Elementary School

Mr. Randy Stephens, Principal 802 20th_{Street NW}

Cleveland, TN 37311 Voice: (423) 476-8246 Fax: (423) 479-5016



Teen Learning Center Mrs. Barbara Ector, Principal 350 Central Avenue NW Cleveland, TN 37311 Voice: (423) 339-0902 Fax: (423) 559-9477



Yates Primary School

Mrs. Carolyn Ingram, Principal 750 Mouse Creek RD NW Cleveland, TN 37312 Voice: (423) 479-1723 Fax: (423) 472-2388

S

TUDENT

I

NFORMATION AND

R

ELEASE

S

IGNATURE

Student Name Parent/Guardian Name

Grade Level Birth Date Previous School’s Name Previous School’s Address Previous School’s Phone Number

Previous School’s Fax Number

I hereby authorize the release of a complete copy of my student’s records to Cleveland City Schools for the purpose of enrollment. Please fax copies of all academic, health-related, and special services records to the number for the school checked above.

Parent/Guardian Signature Date

NOTE: Parental permission is no longer required when records are requested by authorized school personnel in compliance with "Federal Education Rights & Privacy Act, Final Rule on Educational Records, Federal Register, June 17, 1976, Volume 41, No. 118, Page 24675."

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ENGLISH

Migrant Education Program

Occupational Survey

STATE OF TENNESSEE

DEPARTMENT OF EDUCATION

BILL HASLAM 6th_{FLOOR, ANDREW JOHNSON TOWER}_{KEVIN HUFFMAN}

GOVERNOR 710 JAMES ROBERTSON PARKWAY COMMISSIONER

NASHVILLE, TN 37243-0375

Student Information: ______________________________________________________________ Last Name First Name Gender Race School: _____________________________________________Grade:_______ Year: _______

Migrant students may be eligible for additional services and assistance. Please answer the following questions and return the survey to the school so that we can determine if your child qualifies for migrant services.

1. Did you or someone in your family come to Tennessee looking for temporary or seasonal work in agriculture, fishing, dairy, or in any plant processing foods (examples: working with tobacco, tomatoes, cotton,

strawberries, nurseries, trees, pork, chickens, vegetables, etc)? YES _____ NO ____

If yes, please mark which member of the family does or did this kind of work: Mother ____ Father ____ Children ____ Other _____

2. Do you or someone in your family currently work in agriculture fishing, dairy, or in any plant processing foods (examples: working with tobacco tomatoes, cotton, strawberries, nurseries, trees, pork, chicken, vegetables, etc).

YES _____ NO ____

If yes, please mark which member of the family does this kind of work: Mother ____ Father ____ Children ____ Other _____

3. If your current job is not temporary work in agriculture or fishing, did you or someone in your family work in a temporary or seasonal agriculture of fishing in the last 3 years?

YES ________ NO_____

If yes, where? _____________ _____________ _____________ City State Country If you answered “yes” to any of the questions above, please answer questions 4 and 5.

4. What is your current address? ___________________________________________________ 5. What is your current telephone number? __________________________________________

NOTE TO THE LEA: PLEASE RETURN COMPILED SURVEYS TO JESSICA CASTANEDA 4660HILLS CREEK ROAD,MCMINNVILLE TN37110

CALL 931-668-4139 IF YOU HAVE QUESTIONS

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SPANISH

STATE OF TENNESSEE

DEPARTMENT OF EDUCATION

BILL HASLAM 6th_{FLOOR, ANDREW JOHNSON TOWER}_{KEVIN HUFFMAN}

GOVERNOR 710 JAMES ROBERTSON PARKWAY COMMISSIONER

NASHVILLE, TN 37243-0375

Programa de Educación para Estudiantes Migrantes

Encuesta Ocupacional

Nombre del Estudiante: _____________________ ____________________ _________ _________ Nombre Apellido Sexo Raza Escuela: ____________________________________________________ Grado: _________ Aňo_____

El Programa de Educación para estudiantes migrantes a través del Departamento de Educación Pública del Estado provee servicios de apoyo a los niños y familias que se han mudado Tennessee en los últimos 3 años. Para calificar en el

programa las familias deben de haberse mudado de un lugar a otro en busca de trabajo temporal en agricultura o pesca. El Programa registra a niños y jóvenes entre las edades de 3 a 21 años (asistan o no a la escuela). Agradecemos que nos ayuden a determinar si su niňo o pariente califica para recibir servicios en este programa. Por favor, conteste las siguientes preguntar y entréguelas a la escuela.

1. ¿Vino usted o alguien en su familia a buscar trabajo temporal en agricultura o en el campo (ejemplo: tabaco, papas, algodón, fresas, viveros, trabajo con árboles, etc.), o de pesca (empacadora de pescados o mariscos) o alguna planta procesadora de alimentos (cerdos, pollos, vegetales, etc.)?

SI ________ NO___________

Si su contestación es si por favor indique que miembro de su familia hizo esta clase de trabajo. Madre_______Padre_________Hijos_______Otros___________

2. Ud. o alguien de su familia trabaja ahora en agricultura (ejemplos : tabaco, papas, algodón, fresas, viveros, trabajo con árboles, etc. ) o en una procesadora de pescado, lechería, o procesando comida (puerco, pollo, vegetales, etc.)

SI ________ NO___________

Si su contestación es si por favor indique que miembro de su familia trabaja en esta clase de trabajo.

Madre_______Padre_________Hijos_______Otros___________

3. ¿Hace cuánto tiempo se mudó a este condado? ______________________________________ Mes Año

4. Si su trabajo actual no se relaciona a la agricultura y pesca, ¿Usted o algún miembro de su familia ha trabajado en dichas actividades en los últimos 3 aňos?

SI ________ NO __________

¿Dónde? ___________________ _________________ ________________ Ciudad Estado País

5. ¿Cuál es su dirección actual? _____________________________________________________ Ciudad Código Postal Teléfono

6. ¿Cuál es su numero del teléfono actual?____________________________

NOTE TO THE LEA: PLEASE RETURN COMPILED SURVEYS TO JESSICA CASTANEDA 4660HILLS CREEK ROAD,MCMINNVILLE TN37110