Hartville R-II School District New Student Application for Enrollment
Application is hereby made by the undersigned that the student described below be enrolled in the educational program of the Hartville R-II School District. I understand that this is only an application for enrollment and that the student must meet the residency and enrollment requirements of the school district prior to being registered into its educational program.
The Safe Schools Act requires information requested in this form. The following information is true and correct.
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Email *
Student Information: Please provide the following background information regarding the student.
Student Last Name:
Student First Name:
Student Middle Name
Other Names Used by Student:
What Hartville R-II school building will your child be attending:
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Graduation Year
Grade Level
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Date of Birth:
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Social Security Number:
Sex:
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Place of Birth:
Mailing Address: (Street, City, State, Zip):
Residence Physical Address: (Street, City, State, Zip):
Home Telephone Number :
Parent Cell Phone Number:
Parent Cell Phone Number:
Parent E-Mail Address:
Student Resides with:
If student resides with "Other", please explain below:
Student's physical address: (Street, City, State, Zip)
Does your child currently have an IEP?
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What type of IEP program is your child enrolled?
Race
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Student's Parent/Guardian: Please provide the following information about student's parents, step-parents, and/or guardians.
Please answer the following information for Father, Step Father, or Guardian:
Information for:
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Last Name:
First Name:
Middle Name:
Living:
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Date of Birth:
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Residence Address; (Street, City, State, Zip)
Home Telephone Number:
Cell Phone Number;
Employer:
Business Telephone:
Town where employed:
Please answer the following questions for student's Mother, Step Mother, or Guardian
Information for:
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Last Name:
First Name:
Middle Name:
Residence Address (Street, City, State, Zip)
Home Telephone Number:
Cell Phone Number:
Employer:
Please describe any custody arrangements and court ordered information regarding your child below: (Documentation must be emailed or delivered to the respective office)
Brothers/Sisters and Birthdates
During the past three years has either the parent or guardian or the child, been employed (or are any of the aforementioned persons currently employed in some form of temporary or seasonal agricultural or seasonal or agricultural-related work such as: Planting or harvesting, Transporting farm products to market, gathering eggs, working in hatcheries, feeding or processing poultry, beef, hogs, working on a dairy farm or catfish farm, or cutting firewood or logs to sell.
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Does the student use a language other than English?
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Is a language other than English used in the home?
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Are you sharing the housing of other persons due to a loss of housing, economic hardship, or a similar reason?
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If a similar reason, please explain:
Does the student currently residing at a motel, hotel, or camping grounds due to the lack of alternative adequate accommodations?
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Has the student been abandoned in a hospital?
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Are you currently residing in an emergency or transitional shelter?
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Are you currently living in a car, park, public space, abandoned building, substandard housing, bus or train station, or similar setting?
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Virtual Instruction
In accordance with Missouri State Statute 161.670 Hartville R-II Schools offers virtual instruction through Missouri Course Access Program (MOCAP). Hartville R-II board policy IGCD provides guidance for virtual course enrollment.
In Case of Emergency, If Parents Are Not Available, Contacts:
Emergency Contact #1: (Name)
Phone Number:
Relationship
Emergency Contact #2: (Name)
Phone:
Relationship:
List any brothers or sisters attending Hartville R-II Schools:
List any restrictions on who may not pick up student:
Previous School Attended By Student: Please provide the following information regarding each school the student has attended during the preceding (12) months.
School 1 Name:
Address: (Street, City, State, Zip)
Attendance Dates: mm/dd/year - mm/dd/year
Reason for Leaving:
School 2 Name:
Address: (Street, City, State, Zip)
Attendance Dates: (mm/dd/year - mm/dd/year)
Reason for Leaving:
School 3 Name:
Address: (Street, City, State, Zip)
Attendance Dates (mm/dd/year - mm/dd/year)
Reason for Leaving:
Extra Curricular Activities/Clubs/Organizations: Please list any extra-curricular activities, clubs, or organizations you have been affiliated with or wish to be at Hartville High School:
Discipline Report:
For each and every suspension and/or expulsion, provide the following information:
Please select the following:
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Name and Address of School District (School District Name, Address)
Name of School
Nature of Offense
Date of Offense:
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Date of Suspension/Expulsion Began
MM
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Date Suspension /Expulsion Ended/Is Scheduled to End
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I hereby certify that I have provided true, complete and accurate information for each and every suspension and/or expulsion imposed upon the student for each and every offense relating to weapons, alcohol, drugs, or for the willful infliction of injury to another student. Please initial:
I hereby swear or affirm that all information I have provided in this document is true, accurate, and complete to the best of my knowledge. Please initial:
I understand that if I have provided any false information in this document that I may be charged with and convicted of a Class B misdemeanor. Please initial:
I also understand that this registration document will be maintained a part of the student's permanent scholastic record. Please initial:
Proof Of Residency or That Request For Waiver Has Been Submitted: I hereby certify as follows:
I, the parent/guardian of the student in this application seeking to register in the Hartville R-II SChool District, and am legally authorized to make educational decisions for the student. I further certify as follows: (Check one category and provide all additional information requested under the category checked. Warning: Under Missouri Law, any person who knowingly submits false information with respect to the following questions, any subparts thereto, or the documents provided to support the responses to such questions, may be charged with and convicted of a Class A misdemeanor).
The student is a legal resident of the district as established by the following:
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Permanent Home Address: (Street, City, State, Zip)
The School Must Have a Copy of Immunizations At Time of Enrollment
Is your child allergic to anything
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If Yes: Please Explain
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