Registration Form
Date:______________
STUDENT INFORMATION:
Child’s Name/Nombre:____________________________________________________ Last First Middle
Grade:___ Social Security No. (optional):______________ Sex: Male___ Female___
Race: Black____ White____ Hispanic____ Asian____
Native Hawaiian/Pacific Islander____ American Indian/Alaskan Native____
Birthdate/Fecha de nacimiento:_____________________________ Age:_________ Bus #:__________
Address of Child/Direccion actual:
Mailing Address:__________________________________________________________ Street/P.O. Box City Zip Code
Street Address: ___________________________________________________________
Street City Zip Code
Home telephone number:_____________________ School Last attended/Escuela:
Name __________________________________________
Address ________________________________________ _________________________________________
City State Zip Code Telephone #:________________ Fax #:__________________
Did your child attend a Pre-K program, public or private, prior to entering Kindergarten? Yes______ No________
If yes, what program:
Public Pre-Kindergarten________ Head Start______ Private Pre-Kindergarten_______ Has this student received any of these services:
Special Education_____ Speech_____ Gifted _____ ESOL/EL_____ SST_____ 504_____ Which school district:________________ School’s Name:________________________ Dates attended:___________________________
Are there any activities that your child may not participate in due to religious activities?_______________
School Official Use Only:
FAMILY INFORMATION:
Father/Padre/Guardian:Name:______________________________________
Address______________________________________________________________
Street/P.O. Box City State Zip Code
Home/casa Phone #___________________ Cell/cellular_______________________ Place of Employment________________________ Work Phone #______________ Email Address: ____________________________
Mother/Madre/Guardian:
Name______________________________________
Address_________________________________________________________________
Street/P.O. Box City State Zip Code
Home/casa Phone #_____________________ Cell/cellular__________________ Place of Employment_________________________ Work Phone #________________ Email Address: _____________________________
Are you in the Military and based in Albany? Yes_____ No____ Person to contact if Parent/Guardian cannot be reached:
Name___________________________ Address________________________ Telephone ___________________ cell phone_________________________
Persons with permission to pick up this child:
Name_________________________________________
Address_______________________________________Telephone # _______________ Name___________________________________
Address_______________________________________ Telephone # ______________
Person(s) who MAY NOT pick up my child: Relationship:
________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ In case of accident or serious illness, I request the school to contact me. If the school is unable to reach me, I hereby authorize the school to call the physician indicated below and to follow his/her instructions. If it is impossible to contact this physician, the school may make whatever arrangements seem necessary.
Signature of Parent or Guardian_________________________________________ Local Physician’s Name_________________________Telephone_____________ Allergies_____________________________
Routine medications_________________________________ Does child have a health problem? Yes________ No________
Registration Form REQUIRED INFORMATION:
If student was not born in the USA, list country of birth__________________________ If not the USA, answer questions 1 and 2.
1. What date did the student first enter any US School? ________
2. Has this student been attending school in the US more than three full academic years? Yes __No___
3. Have you ever worked or come here with the intention of working in the fields, poultry, and meat processing plant, pulpwood timber industry, fishing or any other agricultural jobs?/¿Ha trabajado o ha venido con la intencion de trabajar en el campo, la pollera, procesadora de carne, sembrando y cortando arboles, pesca, o algun otro tipo de trabajo en la agricultura? Yes/Si ________ No _______
4. How many families live in the house? ______ Is this temporary? ________
What relationship are you to the Head of Household?_______________________ 5. Is language other than English used in the home? Yes______ No______
6. Did student have a first language other than English? Yes_______No______ 7. Does the student speak a language other than English most of the time? Yes_____ No_____
If YES to questions 5, 6, or 7, what is the language? _______________________ Registrars: If yes to Questions 2, 3, 5, 6, or 7 contact Christie Foerster at 776-8600. Names of Brothers and Sisters:
Name/Nombre Age Birthdate Grade/Grado School/Escuela
Directions to home from school/Direccion actual:
______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________
Parent/Legal Guardian Signature:_____________________________
Date:_____________
These rules state that school officials in school systems in which the student may intend to enroll may release and receive a student’s records without written consent for each release.
Records Request:
Date:_____________________
Student’s Name:_____________________________ Date of Birth:_______________________________ Grade:_____________________________________
School Requesting Information
Name: Worth County High School Address: 406 West King Street
Sylvester, GA. 31791
Telephone #: 229-776-8625 Fax #: 229-777-2075
School Releasing Information (Provided by parent)
Name:_________________________________________________________ Address:_______________________________________________________ ________________________________________________________
City State Zip Code Telephone #:__________________ Fax #:_________________________
The student listed above is seeking admission to Worth County Schools. Please assist us by providing the information listed below:
Standard Educational Record Section 504 Plan
Immunization Certificate Eye Ear & Dental Certificate Gifted Eligibility ESOL/ELL Record
Disciplinary Transcript Social Security Number
Birth Certificate Ninth Grade Enrollment Date (High School Only) Withdrawal Form Attendance Record
Any other information that is vital to the student’s education
School Official Signature:____________________________
Georgia House Bill 180 provides that a student enrolling for the first time in any school in grades seven or higher must provide a copy of his or her scholastic and discipline records. Every school system in the State of Georgia must provide complete information to a requesting school within ten (10) days of receipt of such request.
Georgia requires that all students entering Georgia schools for the first time, regardless of their grade level, provide a shot record showing that they are adequately immunized. Please include this shot record in your release along with all available school records including psychological, a copy of standardized test scores, social security card, certified birth certificate, screening and health information.
Registration Form
RACE/ETHNICITY SURVEY FOR THE WORTH COUNTY SCHOOL SYSTEM
The US Department of Education requires the use of new ethnicity/race codes beginning in August of 2009. All parents must complete this survey for each child so we can prepare for the required reporting.
Student's Full Name: ____________________________________________________ Homeroom Teacher: ____________________________________ Grade:__________ School: _______________________________________________________________ Parent's Signature: ______________________________________________________
1. EVERYONE must answer the following question. Choose the correct answer. Is your ethnicity Hispanic/Latino/Spanish Origin regardless of race? _____ YES
_____ NO
2. EVERYONE must select ONE OR MORE of the following races regardless of how you answered question one.
_____ a. White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa)
_____ b. Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam)
_____ c. 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. Black or African American (A person having origins in any of the Black racial groups of Africa)
_____ e. American Indian or Alaskan Native (A person having origins in any of the original peoples of North and South America including Central America), who maintains a tribal affiliation or community attachment.
“Making Education Work for All Georgians”
1854 Twin Towers East • 205 Jesse Hill Jr. Drive • Atlanta, GA 30334 • www.gadoe.org An Equal Opportunity Employer
Parent Occupational Survey
Please complete this form to determine if your child(ren) qualify to receive additional services under Title I, Part C
Has your family moved in order to work in another city, county, or state, in the last three (3) years? £ Yes £ No If so, what is the date your family arrived in the city/town you reside? ________________________________________
Has anyone in your immediate family been involved in one of the following occupations, either full or part-time or temporarily during the last three (3) years? (Check all that apply)
£ 1) Agriculture; planting/picking vegetables or fruits such as tomatoes, squash, grapes, onions, strawberries, blueberries, etc.
£ 2) Planting, growing, or cutting trees (pulpwood)/raking pine straw
£ 3) Processing/packing agricultural products
£ 4) Dairy/Poultry/Livestock
£ 5) Meatpacking/Meat processing/Seafood
£ 6) Fishing or fish farms
£ 7) Other (Please specify occupation): ____________________________________________________________________
Name of Student(s) Name of School Grade
____________________________________ _____________________________ __________________ ____________________________________ _____________________________ __________________ ____________________________________ _____________________________ __________________ ____________________________________ _____________________________ __________________ Names of Parent(s) or Legal Guardian(s) ______________________________________________________________
Current Address: ____________________________________________________________________________________ City: _______________ State: __________ Zip Code: _______________ Phone: ________________________________
Thank You!
Please return this form to the school
The answers to this survey will help determine if your child(ren) are eligible to receive supplemental services from the Title I, Part C Program.
Note for the school/district: When both “yes” and one or more of the boxes from 1 to 7 is/are checked, please give this form to the migrant liaison or migrant contact for your school/district. Please file original in student’s records. Non-funded (consortium) systems should fax occupational parent surveys
to the regional MEP office serving their district. For additional questions regarding this form, please call the MEP office serving your district:
GaDOE Region 1 MEP,P.0. Box 780, 201 West Lee Street Brooklet, GA 30415 Toll Free (800) 621-5217 Fax (912) 842-5440
GaDOE Region 2 MEP, 221 N. Robinson Street, Lenox, GA 31637 Toll Free (866) 505-3182 Fax (229) 546-3251
GaDOE Region 3 MEP, 1414 Twin Towers West, 205 Jesse Hill Jr. Drive SE, Atlanta, GA 30334 Toll Free (800) 648-0892 Fax (770) 359-4827
“Making Education Work for All Georgians”
1854 Twin Towers East • 205 Jesse Hill Jr. Drive • Atlanta, GA 30334 • www.gadoe.org An Equal Opportunity Employer
Encuesta Ocupacional para Padres
Por favor llene este formulario para determinar si sus hijos califican para recibir servicios a través del Programa de Titulo I, Parte C
¿Ustedes se han movido para trabajar en otra ciudad, condado, o estado, en los últimos tres (3) años? £ Sí £No Si su respuesta es “Sí”, ¿en qué fecha llegaron a la ciudad/pueblo donde viven actualmente? ______________________
¿Alguien de su familia trabaja, ha trabajado, o tiene la intención de trabajar, en una de las siguientes actividades en forma permanente o temporal o ha hecho este tipo de trabajo en los últimos tres años? (Marque todos los que apliquen)
£ 1) Agricultura; plantando/cosechando vegetales o frutas como tomates, calabazas, uvas, cebollas, fresas, arándanos, etc.
£ 2) Plantando o cortando árboles/juntando agujas de pino (pine straw)
£ 3) Procesando /empacando productos agrícolas
£ 4) Lechería o ganadería
£ 5) Empacadoras o procesadoras de carne/pollo o mariscos
£ 6) Pescando o criando pescado
£ 7) Otra actividad. Por Favor especifique en cuál: _________________________________________________________ Nombre de los Estudiantes Nombre de la Escuela Grado
____________________________________ _____________________________ __________________ ____________________________________ _____________________________ __________________ ____________________________________ _____________________________ __________________ ____________________________________ _____________________________ __________________ Nombre de los padres o guardianes legales: ______________________________________________________________ Dirección donde vive: ________________________________________________________________________________ Ciudad: _______________ Estado: __________ Código Postal: _______________ Teléfono: ______________________
¡Muchas Gracias!
Por favor regrese este formulario a la escuela
Las respuestas a este formulario van a ayudar a determinar si sus hijos califican para recibir servicios a través del programa de Titulo I, Parte C.
Note for the school/district: When both (Yes) “Si” and one or more of the boxes from 1 to 7 is/are checked, please give this form to the migrant liaison or migrant contact for your school/district. Please file original in student’s records. Non-funded (consortium) systems should fax occupational parent surveys to the regional MEP office serving their district. For additional questions regarding this form, please call the MEP office serving your district:
GaDOE Region 1 MEP,P.0. Box 780, 201 West Lee Street Brooklet, GA 30415 Toll Free (800) 621-5217 Fax (912) 842-5440
GaDOE Region 2 MEP, 221 N. Robinson Street, Lenox, GA 31637 Toll Free (866) 505-3182 Fax (229) 546-3251
GaDOE Region 3 MEP, 1414 Twin Towers West, 205 Jesse Hill Jr. Drive SE, Atlanta, GA 30334 Toll Free (800) 648-0892 Fax (770) 359-4827
