Enrollment Card
 Share
The version of the browser you are using is no longer supported. Please upgrade to a supported browser.Dismiss

 
View only
 
 
ABCDEFGHIJKLMNOPQRSTUVWXYZ
1
Coloma Community Schools Enrollment Form (please print clearly)
2
For Office Use:Grade ______ SC ______ NR ______ 24B _____McKinney-Vento Date Given: ___/___/____
3
4
STUDENT INFORMATION
5
Last Name (as it appears on Birth Certificate)
First Name (as it appears on Birth Certificate)
Middle Name (as it appears on Birth Certificate)
6
Student's Date of birth (mm/dd/yyyy)
Student's place of birth
Gender: ____ Female ____ Male
7
Is there a current Order of Protection or No Contact Order which concerns this student?
___ Yes ____ No
Custody/ Friend of the Court papers?___Yes___ No
8
9
CURRENT RESIDENTIAL ADDRESS
10
Street Address
Apt #City StateZipIs this temporary housing due to a hardship? ___Y ___N Date Occurred: ____/____/______
11
MAILING ADDRESS
(If different than listed above)
LANDLINE/HOME PHONE #
12
Street AddressApt #CityStateZip
13
OTHER STUDENT INFORMATION
14
Does the student have an IEP? ___ Y ___ N
Does the student receive any 504 services? ___ Y ___ N
15
Last school student attended
City/State
Previous Grade
Has student attended CCS before? ___ Y ___ N
16
PARENT/GUARDIAN INFORMATION
17
Birth Mother
Legal Guardian __Y__N
Cell Phone
Employer
Work Phone
18
Birth Father
Legal Guardian __Y__N
Cell Phone
Employer
Work Phone
19
Email Address (Mother)
Active Military? ___ Y ___ N
Email Address (Father)
Active Military? ___ Y ___ N
20
PRIMARY HOUSEHOLD With whom does child reside? (if different from above)
21
Parent A
Legal Guardian __Y__N
Cell Phone
EmployerWork Phone
Relationship to the student
22
Parent B
Legal Guardian __Y__N
Cell Phone
EmployerWork Phone
Relationship to the student
23
Email Address Parent A
Active Military? ___ Y ___ N
Email Address Parent B
Active Military? ___ Y ___ N
24
SECONDARY HOUSEHOLD (Only fill out if applicable): Does the child have a second residence?
25
Parent C
Legal Guardian __Y__N
Cell Phone
EmployerWork Phone
Relationship to the student
26
Parent D
Legal Guardian __Y__N
Cell Phone
EmployerWork Phone
Relationship to the student
27
Email Address Parent C
Active Military? ___ Y ___ N
Email Address Parent D
Active Military? ___ Y ___ N
28
ETHNICITY
29
1. Is the student Hispanic or Latino?
__ Yes__ No
30
2. What is the student's ethnicity/race? (Select all that apply)
31
[ ] American Indian
[ ] Asian
[ ] African American
[ ] Hispanic/Latino
[ ] Native Hawaiian/Pacific Islander
[ ] White
32
Student's country of birth?
Does the student speak english? ___ Y ___ N
What is the primary language spoken at home?
33
34
EMERGENCY CONTACT and/or PERSON TO PICK STUDENT UP FROM SCHOOL
35
Must be different from parent/guardian information; Person must be 18 years of age. (please list at least 2 contacts)
36
1. First & Last Name
Relationship to the Student
37
Home phone number
Cell phone number
Work phone number
38
2. First & Last Name
Relationship to the Student
39
Home phone number
Cell phone number
Work phone number
40
3. First & Last Name
Relationship to the Student
41
Home phone number
Cell phone number
Work phone number
42
MEDICAL CONDITIONS
43
Please list any special condtions for your student (asthma, medications, migraines):
44
CONSENT TO RELEASE STUDENT INFORMATION
45
These consents will be in effect for the current school year and are in compliance with the FERPA (Family Educational Rights & Privacy Act)
46
A. My child may be photographed, video recorded, interviewed, televised including website and/or social media (school-related)
__ Yes __ No
47
B. My child may be photographed, video recorded, interviewed, televised including website and/or social media (district-related)
__ Yes __ No
48
C. The school and/or district may publish my child's name for school achievement's (honor roll) and/or extracurricular activities (sports)
__ Yes __ No
49
50
PROOF OF RESIDENCE (Required for Resident students only)
51
In order to satisfy Michigan Department of Education residency verification requirements, parents or Guardians must provide two
52
documents from the list below:
53
[ ] Copy of Driver's License or State ID Card
54
[ ] Active bank account of name and address imprinted
55
[ ] Current utility bill (gas, electric, phone)
56
[ ] Deed to home with address
57
[ ] Rental receipt with address of home or apartment
58
I, Certify that the above information is true to the best of my knowledge. Falsification of any information/document required for
59
this verification could result in revocation of registration for the student(s).
60
61
62
______________________________________________________________
_________________________________
63
Parent/Guardian Signature
Date
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
Loading...
Main menu