2021-22 Clearwater Preschool Enrollment
This is enrollment for the Clearwater R-1 School District.  Your child must turn 4 by July 31, 2021. Fill this out completely and submit it.  
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Legal Name of child (Last, First Middle) *
Preferred Name (if different)
Date of Birth (MM/DD/YEAR) *
MM
/
DD
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YYYY
Previous Last Name (if different)
Gender *
Ethnic/ Race (Check one box for Ethnicity and one box for Race.) The U.S. Department of Education requires all states to collect data on student ethnicity and race. Please indicate student's ethnicity and race by checking one box for each. *
Required
PRIMARY HOUSEHOLD PARENT: (Parent/guardian with whom the child lives) Current Address: *
PRIMARY HOUSEHOLD PARENT HOME PHONE: *
Internet Service *
Cell Phone Signal *
Student lives with:(choose one) *
Marital Status of Primary Household *
Primary Parent/Guardian Contact #1 (Name, Relation to Student, Cell Phone, E-mail Address, Employer, Employer Phone) List all below: *
Primary Parent/Guardian Contact #2 (Name, Relation to Student, Cell Phone, E-mail Address, Employer, Employer Phone) List all below: *
How long as the student lived at the current address? *
In what county is this address? *
What proof of residency is provided? *
Will your child ride the bus? *
Required
SECONDARY PARENT HOUSEHOLD (not student's primary residence) CURRENT ADDRESS:
SECONDARY PARENT HOUSEHOLD (not student's primary residence) PHONE NUMBER:
Marital Status of Secondary Household
Clear selection
Secondary Parent/Guardian Contact #1 (Name, Relation to Student, Cell Phone, E-mail Address, Employer) List all below:
May we contact this person in case of an emergency?
Clear selection
Secondary Parent/Guardian Contact #2 (Name, Relation to Student, Cell Phone, E-mail Address, Employer) List all below:
May we contact this person in case of an emergency?
Clear selection
Emergency Contact #1:(Please list persons to contact in the event of an emergency and we are unable to reach either parent.) Name and Relation to student, Home Phone, Cell Phone, Work Phone *
Emergency Contact #2:(Please list persons to contact in the event of an emergency and we are unable to reach either parent.) Name and Relation to student, Home Phone, Cell Phone, Work Phone *
COURT ORDER (A complete original copy of any legal documents/court orders pertaining to the student must be presented to the school. Such as divorce decrees, custody, parenting plan, restraining order, etc.) *
Required
Is there a court order that restricts either parent from contact with your student or access to student records? (If such a court order exists, it is the Parent's/Guardian's responsibility to provide a copy of this court order to the school.  It must be on file in the school's office to act on any restrictions.) *
Restricted Pick Up ( If yes, then please list the person or persons)
Did the student bring a copy of their school records? (Official records from other school will be requested.) *
Was the student previously enrolled in the Clearwater  R-1 School District? Yes/No (If yes, what grade?) *
Has the student ever been retained? Yes/No (If yes, what grade was repeated?) *
Does the student speak a language other than English as the primary form of communication? Yes/No (If yes, what language?) *
Is a language other than English spoken in the home as a form of communication? Yes/No (If yes, what language?) *
Does or has the student received ELL(English Language Learner) services? *
Date entered the United States:
MM
/
DD
/
YYYY
Do you currently share the housing of other persons due to loss of housing or economic hardship? Yes/No (If yes, please explain) *
Do you reside in a hotel/motel, car/campground, or transitional shelter due to loss of housing or economic hardship? Yes/No (If yes, please expain.) *
Do you currently reside in a shelter? *
Do you currently live in a temporary housing arrangement due to economic hardship? *
Has the family moved within the past 3 years to obtain temporary or seasonal farm-related work such as planting or harvesting crops; transporting farm products to market; feeding or processing poultry, beef or hogs; gathering eggs or working hatcheries; working on a dairy farm or a catfish farm; or cutting firewood or logs to sell? *
Who is the educational decision-maker for this child? *
Is there a need for an educational surrogate? Yes/No (If yes, who?) *
Is the student currently receiving special education services under the Individuals with Disabilities Education Act (IDEA)? *
Is the student currently receiving Section 504 accommodations? *
Is the student currently receiving Title1 or Remedial Reading/Comm. Arts/Math services? *
Is the student currently receiving Formal Gifted Program services? *
Has the student received any of the above services in the past? Yes/No (If yes, please explain.) *
DIRECTORY INFORMATION: Under Federal Education Rights and Privacy Act, public school districts are allowed to release directory information such as a student's name, grade level, parent/guardian names, address, telephone number, electronic mail address, participation in activities and sports, weight and height of members of athletic teams, most recent school attended, dates of attendance, honors ad awards received, degree received, enrollment status, artwork or coursework displayed by the District, and photographs, videotapes, digital images and recorded sound, unless such would be considered harmful or an invasion of privacy.  This includes school pictures, yearbooks, and the district's website.  Denial of permission does not affect the district's authority to use video cameras for law enforcement and discipline purposes. *
Required
Activities (MISSOURI STTE HIGH SCHOOL ACTIVITIES ASSOCIATION - MSHSAA PARTICIPATION) (For 7-12th grades)  Is the student planning on participating in MSHSAA sponsored activities? Yes/No (If yes, list activities):
If you answered yes on the previous question, then list Previous Home Address, and Name of Previous School.
MILITARY RECRUITER ACCESS TO STUDENT INFORMATION (HIGH SCHOOL STUDENTS ONLY):  BY LAW THE DISTRICT MUST RELEASE TO MILITRY RECRUITERS THE NAME, ADDRESS, AND PHONE NUMBERS OF HIGH SCHOOL STUDENTS UNLESS THE STUDENT, PARENT, OR GUARDIAN NOTIFIES THE DISTRICT IN WRITING THAT THEY DO NOT WANT THE INFORMATION RELEASE. NOTIFICATION IN WRITING MUST BE RECEIVED BY THE SCHOOL 10 DAYS AFTER COMPLETING THIS FORM.
Transfer of school records:  Parent or guardian must be able to provide the names and addresses of all schools previously attended.  Students may be allowed to attend the day after enrollment in order to obtain transferring record information.  At time of enrollment, parent or guardian must indicate whether or not the child received any special services as provided by IDEA (PL 94-142).  If special services are required, students will be allowed to start at the time that records are received from another district or when adequate information can be obtained to confirm placement  and services from the previous district. NOTICE: In accordance with state law, our district provides the option to enroll in approved virtual courses including courses offered through MOCAP. *
Required
MISSOURI SAFE SCHOOLS ACT:  Was the student involved in discipline problems at the previous school? Yes/No If yes, explain: *
MISSOURI SAFE SCHOOLS ACT: Is the student currently under suspension or expulsion from school? Yes/No If yes, state the reason(s) for the suspension/expulsion. *
MISSOURI SAFE SCHOOLS ACT:  Has the student  ever been convicted of a felony (or indicted or had any information filed against him/her alleging the commission  of a felony for which there has been no final judgement)? Yes/No  If yes, explain: *
MISSOURI SAFE SCHOOLS ACT:  Has the student ever had a petition filed against him/her in juvenile court alleging the commission of an act that, if committed by an adult, may constitute a felony, for which there has been no final judgement, or for which the student has been adjudicated to have committed the offense? Yes/No  If yes, explain: *
MISSOURI SAFE SCHOOLS ACT:  Is the student  under the jurisdiction of the Family or Juvenile Court? Yes/No  If yes, please provide the name and phone number of current juvenile officer and city and state. *
Submitting false statements or information relating to residency is defined as a Class A misdemeanor.  Submitting false statements or information relating to student's disciplinary history is defined as a Class B misdemeanor.  Students also face potential removal from school if false statements or information regarding residency or disciplinary history are given. *
Required
Under penalty of applicable Missouri law, I/we certify to the best of my/our knowledge, the information given on this form and the enrollment from is correct and complete as it pertains to the student's disciplinary history with regard to suspensions from school in the last two school years and to expulsion from any school for any offenses in violation of board policies relating to weapons, alcohol and drugs, or for the willful infliction of injury to another person.  I/We further acknowledge and accept responsibility for the consequences of submitting false statements or information for the purpose of enrollment.                       Yes, I read this section. List Custodial Parent/Legal Guardian Name and  Date,  Student Name and Date *
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