EFTA01710166.pdf

EFTA01710166 EFTA01710167  . _., THE SCHOOL DISTRICT OF STUDENT NUMBER: too: . Ly ..,. :-. PALM BEACH COUNTY VERIFICATION FOR NEW/RETURNING STUDENTS: TO THE PARENTS OR GUARDIANS: .---. NEW/RETURNING STUDENTS NEW STUDENTS: Complete all non-shaded areas on both sides of form REGISTRATION RETURNING STUDENTS: Please review both sides for correctness 01 typed information. If the intormaton printod is incOrrOCt, please correct it by carefully ISTR:2511 TCHR:PUTIGNA, E TNER:163STOT: 13642421 and lightly crossing out the incorrect information and a..03/30/00 writing the correct information above it C2,6 0 - 08:3 408 Sc I-On II) STUDENTS LEGAL HARM BEAR? 4:14> ANA -424 ' 1 (2) ALSO 'MORN AS i...ST 13) LOCAL ADDRESS (4, GUn IVG ADDRESS s., 4. .C./.1 he mar MAW( a, , ;ar orES 41 Vrilt, 4• Ml cn, sr *Tr t, car ',We rrAW isi metiers SOCIAL SECURITY NO. 161 HOME >HONE N0. il ) SEX (8) RACE (OPTIONAL) I remAte e F . AMERICAN INNAN OP ALASKAN NATIvE. D ttl C i ti:IC ISLANDER 1 W yy:::,...,,,,..,<, A 3 MALE I B ' NON -HISPANIC H HISPANIC 0 M v..,..0... I (9) DATE OF BIRTH (IEN PLACE Of BIRTH 000ro Art FL U$,,,, FL0RID4,,,„, , n'' (II/ RES:DENT STATUS 112E ENTRY DATE INTO USA 3 0. FOREIGN EXCHANGE STUDENT 2. OUT -Of -STATE RESIDENT I I. OUT -OF -COUNTY RESILIENT 0 3. IN-COUNTY RESICENT 113) FEDERAL iNVIACT A 0 SURVEY 9 YES 0 NO A. THE STUDENT FESIDES ON FEDERAL PROPERTY. 0 TES YES I 0 NU NO B. THE SIAM PE SILES IN NW KENT HOUSING. C. THE PARENT IS EMALMID DN LEDERAL PROPERTY LOCATED IN PALM BEACH COUNT/. O HS 0 YES 0 NO NO D. THE PARENT IS MAIMED ON .OW RENT HOUSING LOCATED IN PALM BEAN COUNTY. E. THE PARENT IS IN THE UNIFORMED SERVICES OF TIE UNITED STATES. IF IFS. IS THE PARENT ON ACTIVE MITT? 0 YES 0 MO AIR FORCE 0 ARMY 0 COAST GUARD N MARINES 0 NATIONAL GUARD ll NAVY 1 41 HAS THIS OHIO REIN ENROLLED IN AN PRY srannt, CEASE PLACE A DICKMAN( I jar SY EACH PROGRAM ATTENDED. ALSO, INDICATE WITH AN ASTERISK I *) NE PROGRAM TIM CHILD SAS IN THE LONGEST.) C. CHAPTER I 0 It NIAUSTANI 0 0 OTHER C. PREK DISABILITIES li MIGRANT PAT -K 0 S SIRSIPIIFIL El•Illl CAM I I 9 1. PRE-K EARLY INTERVENTION 9 N. NON-SUBSIDIZED CHILD CARE OM IS NE STUDENT A SINGLE PARENT? NO 9 us 0 MO 116) CuRRINY GRADE lE4 08 TRANSFER INFORMATION: (II) NAME OF SCHOO. TRANSFERRING FROM (I8/ CITY OR IODATION (19) DATE Of LAST ATTENDANCE 120E GRADE LEVEL (211 LAST PUBLIC SCHOOL ATTENDED IN PALM BEACH COUNTY (22) DATE ATTENDED FREE OR REDUCED PRICE LUNCH AND HEALTH INFORMATION: (23) NAVE YOU FILLED OUT AN APPLICATION FOR FREE OR REDUCED LUNCH? II YES Ill NO (APPLICATION IS PROVIDED WITH THIS REGISIP.ATION IOW/ (24) HEALTH SCREENINGS: I GIVE PERMSSION FOR MY CHILD TO IN G AEN HEALTH SCREENINGS. THESE TESTS MAY BE GIVEN INCIVIDUALLY OR IN GROUPS. 0 YES 0 NO NO (251 $00iuM FLUORIDE: I GIVE PERMISSION FOR MY CHILD TO PART CIPATE IN THE SODIUM FLUORINE PROGRAM TO PREVENT DENTAL DECAY. PERMISSION IS VALID THROUG1 GRADE SIR 0 YES 0 no NO NEW STUDENTS TO PALM BEACH COUNTY: HOME LANGUAGE SURVEY UM WHAT LANGUAGE IS SPOLEN IN THE HON! kri WHAT LANGUAGE IS SPOLEN 28) DATE Of NM BY THE PARENT or GUARDIAN. IN THE ROME BY THE STUDENT? INTO THE ESN PROGRAM 129) LANGUAGE SURVEY (30) DISCLOSURES Ia lirst say MID I. IS A LANGUAGE OTHER THAN ENGLIST USED IN HE HOME? OTIS 0 NO Ellis SCHOOL DISTRICT 2 OMIS THE ST,IDENT HAVE A IIRST LANGUAGE OTHER THAN ENGLISH? ,YES El NO HAS THE STUDENT EVER. 3. DOES nit STUDENT MOST FREQUENTLY SPEAR A LANGUAGE OTHER THAN ENGLISH? OILS Ill NU I. BEEN EXPELLED FROM SCHOOL? 0 YC 0 YO 2. HAD AN ARREST RESULTING IN A CHARGE? 0 t> 0 NU 3. HAD AM JAVENILE JUSTICE ACTIONS? ll EL NO ■0 EFTA01710168  THE SCHOOL DISTRICT Of PALM BEACH COUNTY - NEW/RETURNING STUDENTS REGISTRATION BACK (31) STUDENT LIVES WITH (CHECK ONE) 0 BOTH PARENTS s MOTHER El FATHER ❑SHARED CUSTODY E OTHER (32) TRANSPORTED BY Swart em tie %raspy/IAA le/Lem EON', oy has ,I *Ow Than IMF OM/ T33) IS THERE A COURT ORDER BARRING EITHER PANEW INDIA REMOVING OR CON- ACING THE STJOENT DURING THE SCHOOL DATE YES 0 NO 0 IF YES, PLEASE PROVIDE THE SCHOOL WITH A COPY OF THE COURT ORDER (34) FATKER/GUAREHAN DOES FATHER HAVE CUSTODY, OYES Elmo (351 MOTHER. GUAR MAN DDES MOTHER HAVE CUSTOM! ) D YES 0 NO YES YES ll MOKI LAM it' a a ... LAST FL 33470 FL 33470 . • < NOME /430MSS CM ST AR aCOOS e4JA. Kw (tAa OF ONUNNOWT MCI OP MaCinaDir NOM MOM Mufti LORI CO4 Fwom ARAM POI 1361 HIGHEST lEvEl OF EDUCATION COMPLETO (OPTIONAL) (311 NIGH.ST 'Eva OP EDUCATION COmPTETED )OPTIONAL) An OAMINTAP• toga BO or 0 1003. C 0 0 litSOOL AD :r aj ln:i IICH:a B 0 tan NO. til00( C SOCO. twat .r.e auers 1.1E. Featousvo wawa 6.I. [le anuAto D 0 .....or.stc..... TIOAtiCALFTWOD ra,scsucmisot E D COSA I ., Mal, '"'"`",,,,a D 0 „,,, nnte `s- E 0 nal.‘"jc„ aua 1310 LEGAL GUARDIAN PR AIM DOES LEGAL GUARDIAN HAVE CJSTODYT Ill YES n Na is L. .0.41 &OOMit CITY PATE IMERCIENCY HEALTH AND SAFETY INFORMATION PART I PERSONS) OTHER THAN PARENT AUTHORIZED TO PICK UP STUDENT 091 PASSWCRD OMIT 10 CHARACTERS) In NPLLe (II) NAME ADDRESS PHONE RELA'IONSHIP C- 1 u YES 0 NO OW NAME ADDRESS PHONE RELATIONSHIP n U YES 0 NO (431 NAME ADDRESS PHONE RELATIONS/4M rl U YES 0 NO (441 NAME ADDRESS PHONE EFL ATTONSHIP I- 1 u YES 0 NO (45) NAME POORESS PRONE PELAIK)ESHIP rn u YES 0 NO ICE) PART II F SCHOOL PERSONNEL ARE UNABLE TO CONTACT YOU IN CASE OF ILLNESS OR ACCIDENT. MAY WE HAVE YOUR PERMISSION TO CALL YOUR DOCTOR OR IMERGENC, SERVICES (III) POR TRANSPORT TO THE HOSPITAL' • YES C3 N3 (41) EMILY DOCTOR 148) PHONE NuWEIER (49) HOSPITAL PREFERENCE ISO) LIST YOUR CHAD'S ILLNESSES, ALLERGIES OR CHER PHYSICAL ,IMITATIONS YOUR CHILDREN IN OTHER PALM BEACH COUNTY SCHOOLS: IS 11 NAME Of CH4 0 SCHOOL ATTENDING STOOP(' NO ICPTIONAI) GRADE BIRTH CATE 1021 NAME OF CHAO SCHOOL ATTENDING STUDENT NC. (OPTIONAL) GRADE BIRTH DATE 1531 RAW OF CHILD SCHOOL ATTENDING STUDENT NC. (OPTIONAL GRADE BIRTH DATE 154) NAVE OF CHILD SCHOOL ATTENDING STUDENT NC (OPTIONAL) GRADE BIRTH DATE (551 NAME OF Cm() SCHOOL AT TENDING STUDENT NC. (OPTIONAL GRADE BIRTH DATE 156) 1 VERIFY THAT TIN INFORMATION GIVEN IS TRUE ANO ACCURATE TO THE BEST OF MY INOVILEME SIGMATIRE 3) PARENT OR IF GAL GUARDIAN O..0 FOR OFFICE USE ONLY: DO/ SCHOEN ND (STD QOM; EMINTREA (St SITIOINT t A Main GE ED [CR VII ENTRY (001 U2( ENTRY CATS 4B3L SAC tEVE EN E01 08/16/98 420A 184, PARENT , GLARCIAN LANGUAGE 'lib/ GRADE LENT. (561 CALM OR Nil) TEACHES NE. 2511 EN us 08 01 438) REASSIGNMENT CODE 1611 TRANSPORTATION 70) tE 6 (CATION OF O.RTH 011 EMS 72) DOE MINTATION CDECAUST HECA ANN DATE WHEN gifttriel 0A, AOM ,GATE misuNiZATiONS El 'ATE VISIMICATION Of 074SE 0 YES 0 N?,4 1 z BIRTH RECORDS BI 0B 7 ESOL 010.M0G 0 I I 3 4 s 6 T 3 4 6 6 7 6 9 T AEI CloATE SOCIAL SECURITY n 'ATE la PMCGICAL EXAMS NO OP ORAL OM DATA FERRI COMPIFT(0 St DATE: PBSO 0636 (REV. OM) EFTA01710169  HE SCHOOL DISTRICT OF STUDENT NUMBER oat oks, \ .;7) / PALM BEACH COUNTY 1 r VERIFICATION FOR NEW/RETURNING STUDENTS: TO THE PARENTS OR GUARDIANS: K.. L ..* STUDENTS NEW STUDENTS Complete all non- shaded areas on both 4e., ..",:";NEW/RETURNING sides of form REGISTRATION RETLRNING STUDENTS: Please review both sides for correctness of typed nforrration. If the information printed is incorrect, please correct it by CarefUlly and lightly croSsEng out tho incorroct information and ... ea writing the correct information above it. Cl) STUDENT'S LEGAL NAME 21 ALSO PINONN AS (3) LOCAL ADDRESS 7 2 <T. )•7 L. .i 1.3 4' )Pn—• /.. I C . <foe iligraffini r IS) STIM(NT'S SOCIAL SECLIRIT, N) . 0( S MI RACE PTI NA. 0 I OM frR CAL PI A CsAillAINtOi FEMALE NATIVE I A PArIFNI: 1ISLANDER I W w„.".1(Hip,.., 0 mA., 9 MAC.: NON -HISPANIC 0 El H INSANE. C El M MULL RACIAL MD/ PLACE OF BIRTH MOO. DAY ■ rA en . La‘Pi t 411 CA. F io t do, ..---, (15, III) RESIDENT STATUS, DV ENTRY CATE IN70 USA I 0 Fano IICIWIV STUOINT I 1 OM -Of -STATE RESIDENT I. OUT -OF •CORNTT RESIDENT Et 3. IN-:OURTV RESIN! 1131 FEDERAL IMPACT AID Suarfir 0I 115 TES 0 9 NO NO A. TOE STUDENT RESIDES ON IECERAL PROPERTY, B. TOE STUDENT RESIDES IN LOW RENT VOWING I in ii NO C THE PARENT IS EMPLOYED ON FEDERAL PEOPEATT LOCATED IN PALM BEAN COUNTY. ll YES 0 NO 0 THE PARENT IS EMPLOYED ON LOW RENT HOUSING LOCATED IN PALM BEACH COUNTY. O fFS D NO F TN( PARENT IS IN THE UNIFORMED SERVICES OF THE UNITED STATES. IF YES. IS TIC PARENT ON ACED( GATT? 1:l TES I NO AIR FORCE I ARM) I COAST GEAR( 9 MARINES 0 NATIONAL GUARD I NAVY 04: HAS THIS CHILD BEEN ENROLLED IN ANY PRESCHOOL? LPL; AM PLACE A CHECOAA4K Ike ST EACH PNONKAM ATTENDED. ALSO, ALIKAlt WITH AN AMMO I * I THE PROGRAM TOUR CHEM WAS IN THE LONGEST I C. CHAPTER I I H HEAESTART 9 0 OTHER ll D. PRE-K DISABILITIES I M MIGRANT PRE -IL El S. su6ScIZED CHILD CARE E. PRE-K EARLY INTERVENTION I N. NON-SUBSIDIZED CHILD CARE libi IS THE STUDENT A SINGLE PARENT? IMO `[ARE IT GRAPE LEVEL I Iris NO -01 TRANSFER INFORMATION: (Ill NAME OF SCR( 01 TRANSFERRING FROM IUD CITY OR LOCATICN ILB DATE OF EAST ATTENDANCE (20) GRADE I WI 20 I AST POOL IC SCHOOL ATTEND) S IN PAi Ns RA AIN COUNT( (22 DATE ATTENDED FREE OR REDUCED PRICE LUNCH AND HEALTH INFORMATION: 123) HAiE IOU I DU 0 CUT AN APPLICATION FOR FREE OR REDUCED MOO (APPLICATION IS PROVIDED WITH THIS REGISTRATION FORM/ I IFS 134) HEALTH SCREENINGS: I GIVE PERMISSION FOR Mr CRIED TO BE GIVEN HEALTH SCREENINGS. THESE TESTS MAT BE GIVEN INDIVIDUALLY OR IN GROLPS. YES II NO 1151 SODIUM ILUORIOE: I RIVE PERMISSION ION MC ONItO TO PARTICIPATE IN INF SURMA *IMAM( PROAAM I NO YES TO PREVENT DENTAL DECAY. PERMISSION IS PALM EIROUGII :RARE SIX. NEW STUDENTS TO PALM BEACH COUNTY: HOME LANGUAGE SURVEY '25) WHAT .ANALIAISE Is. SPOKEN IN THE HOME an WHAT IANCJAGE IS SPOKEN URI DATE Of ENTRY BE THE PARENT re GUARINO& IN THE NOME BY TIE STUDENT" INTO TN ESOl PROGRAM 135) LANGUAGE SURVEY ... STUDENT DISCLOSURES FOR 1F , ,. I IS A LANGUAGE OTHER THAN ENGLISH IMO IN THE HOME? IES THE SCHOOL ()STRICT OF Pf <5 Ao , COUNTY 4 ;46 3. DOES THE STUDENT HAS( A FIRST LANGUAGE OTHEF THAN INDIAN, II FOS THE STUDENT EVER S n iv 3 DOES THE STLIIHNT MOST IRFOUENTI Y SPEAK A LANGUAGE OTHER THAN ENGLISH? f( I BEEN ExPILLE0 HUM SCHOOlt 'f' •• 2 MAD AN ARREST RESULTING API 4. 3. HAD AND JUVEIIIII JUSTICE PBSO 0636 IRA7 $/97/ EFTA01710170  THE SCHOOL DISTRICT OF PALM BEACH COUNTY - NEM/RETURNING STUDENTS REGISTRATION BACK IS)) STUD I LIVES WITH (CHICK OKI GOTH PARENTS 0 MOTHER 0 FATHER i SNARID CUSTODY Q OTHER 1 4 1311 TRANSPORTED OY $14.4*.a ..a 4.6 ucitspmned tylinr +w. kw C.. m• 4.4/ I646 p....1) (B3) IS THERE A COURT ORDER BARROIC EITHER PARENT FRoirtEMONNen OR CONTACTING THE STUDENT DURING THE SCHOOL DAY'n YES IF YES, PLEASE PROVIDE THE SCHOOL WITH A COPY OF CA CC:q- THE COURT MUM 74e F. IFER/Gu Al DOES FATHER HAVE CUSTODY YES 0 NO 13.5) MOTHER/GUARDIAN DOES ROPIER HAVE CJSTOOY' CipeES 0 NO C 7O VI ISLVD C OY1Q_ ... . A# H im 1. 4 V L U 1 NB. , R ST LEVE. OF PCUCATiON;OMPTETEID ‘ ICPTIONAll 13 3 • HiGHE t C 0 =try C i ncl. lcbcc. D0 'ow Hn. : 7 ,0 4.6•. D 0 -- ----,-- 0,.....„ E 0 ...r-ar,.:".... - E it conauX4••••1 MARY,. •• mcms D MN LEGAL GUARDIAN OP ANY1 DOES LEGAL GUARDIAN NAVE CUSTODY( 0 !Es 0 No 1 4664444 OT• VATS— 70 em 0•44. is/ INN ang/IT EMERGENCY HEALTH AND SAFETY INFORMATION PART I PERSONISI OTTER THAN PARENT A JTHORI2E0 TO PICK UP STUDENT (3)) PASSWORD fLIMT 10 CHARACTERS) a' " 7"""ZW PO. 0•1001100 PICK/ •• • PHONE RELATIONSHIP /YES Fa ea. 0 NO 1:11tTIONa Bp irec rn. 0 NO ADDRESS REEATIONMiro I- 1 u YES 0 NO IAN ma ADDRESS PHONE RELATIONSHIP rl u YES 0 ND 145) NAME ADDRESS PHONE RLLAIION Sm. r-1 u YES 0 No KM PAR