How did you hear about Byron Center Charter School, if referred, who referred you?

Grade Entering *

Student's Name: (Last, First) *

Date Of Birth *

Home Phone Number *

Student's Street Address: *

City and State *

Zip Code *

Ethnicity (select all that apply) *

Father's Name (Last, First) *

Father's Day Phone or Cell Phone *

Father's Employer *

Father's Home Phone *

Student's Gender *

Guardianship (Student resides with, check all that apply) *

Guardian Email Address (for school news, etc) *

Mother's Name (Last, First) *

Mother's Day Phone or Cell Phone *

Mother's Employer *

Mother's Home Phone Number *

Student's Language *

Home Language *

Enrollment history (for new student's only): Does your child receive any of the following services? *

Is your student currently expelled, suspended, or recommended for expulsion or long-term suspension? *

School Previously Attended *

Emergency Contact Name 1 *

Emergency Contact Phone Number (specify home or cell) *

Emergency Contact Name 2 *

Emergency Contact Phone Number (specify home or cell) *

Medical Information: Please tell us if your student has any medical conditions, allergies or takes any medication that you feel we should be aware of: *

I hereby give permission for my student to be transported in a vehicle and participate in field trips. I understand that field trips are a part of the school's educational program and provides a learning experience of educational value to my student. *

I hereby give permission to Byron Center Charter School to secure emergency medical treatment for the above named student while in their care. Release and agree to hold the Board of Education, It's officials and it's staff harmless from any and all liability for damaged or injury resulting directly or indirectly for this authorization, I understand that the school staff is not medically trained. *

Sharing immunization and personally identifiable information including the student’s name, Date of Birth, gender, and address with local and state health departments will help to keep your child safe from vaccine preventable diseases. The Family Educational Rights and Privacy Act (FERPA), 20 U.S.C. § 1232g, requires written parental consent before personally identifiable information and immunization information from your child’s education records is disclosed to the health department. I authorize Byron Center Charter School to release my child’s immunization record and/or waiver, confirmation of vision screening and personally identifiable information to the Michigan Department of Health and Human Services and Local Health Department. *

Byron Center Charter School is authorized to use our son/daughter's photo/video in school publications/advertisements to promote events and or enrollment in local media, unless a written objection is filed with the office within 3o days of enrollment. *

By typing my name below I affirm, that as the parent/legal guardian, all information provided above is true and accurate, and that my student and I reside at the listed address. I understand any false information provided by me, may subject me to legal penalties for perjury. *