Muncy School District Kindergarten Registration

First/Last Name of Sibling

Birth date of Sibling

Grade of Sibling

Sibling #1

Sibling #2

Sibling #3

Sibling #4

Sibling #5

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Ward L. Myers Elementary School

In addition to completing the on-line registration, a meeting must be scheduled to complete and sign additional documents. These enrollment requirements will include: 1. Proof of the child's age. Any one of the following constitutes acceptable documentation: birth certificate, notarized copy of birth certificate, baptismal certificate, copy of the record of baptism-notarized or duly certified and showing the dates of birth, notarized statement from the parents or another relative indicating the date of birth, a valid passport, a prior school record indicating the date of birth. 2. Documentation of immunizations required by law. Acceptable documentation includes the child's immunization record, a written statement from the former school district or from a medical office that required immunizations have been administered, or that a required series is in progress, or verbal assurance from the former school district or medical office that the required immunizations have been completed, with records to follow. 3. Proof of residency. Acceptable documentation includes a deed, a lease, current utility bill, current credit card bill, property tax bill, vehicle registration driver's license, DOT identification card. A district may require that more than one form of residency confirmation be provided. However, school districts and charter schools should be flexible in verifying residency, and should consider what information is reasonable in light of the family's situation. 4. Parent registration statement (Expulsion affirmation statement) 5. Home Language Survey. All students seeking first time enrollment in a school shall be given a home language survey in accordance with requirements of the U.S. Department of Education's Office for Civil Rights.

Information of Legal Guardian Registering Kindergarten Student*

		First Name		Last Name		Relationship		Phone number		Address
Person Enrolling Student(s)

If the student is living with a resident adult other than a parent, please go to the For Parents/"New Student Registration" section of the Muncy School District Website to complete Attachment C. Print the completed form, have it notarized, and bring it to the registration meeting. If a court or dependency order or custody agreement is used as the basis for enrolling the child, a copy of said document must be provided.

2.	As the person registering the child, what is your relationship?
	As the person registering the child, what is your relationship? Natural mother Natural father Guardian Other, please specify

3.	Student's Date of Birth (Board Policy established the district’s entry age for kindergarten as five (5) years old before September 1 of the enrollment year.)*
	mm/dd/yyyy

4.	First Name of Student*

5.	Middle Name of Student

6.	Last Name of Student*

Student's Home Phone Number:*

Student Phone Number

8.	Student Mailing Address Line 1 (Apt # / Street) *

9.	Student Mailing Address City*

10.	Student Mailing Address State*

11.	Student Mailing Address Zip Code*

12.	Ethnic Group of Student*
	Ethnic Group of Student* White (Non-Hispanic) (5) Black (Non-Hispanic) (3) Hispanic (4) Asian/Pacific Islander (2) Amer Indian/Alaskan Native (1) Multi-Racial/Ethnic (6)

13.	Gender of Student*
	Gender of Student* Male Female

14.	Birthplace of Student (City,State,Zip code)*

15.

Parent / Guardian #1 Contact Information (This is the legal parent/guardian the student lives with) *

		Parent/Guardian #1 First/Last Name		Parent/Guardian #1 Mailing Address (Street/Apt. #)		Parent/Guardian #1 City		Parent/Guardian #1 State		Parent/Guardian #1 Zip Code		Parent/Guardian #1 Cell Phone Number		Parent/Guardian #1 Home/Additional Phone Number		Parent/Guardian #1 email address		Parent/Guardian #1 Place of Employment		Parent/Guardian #1 Employment Phone Number		Relationship to Student
Parent/Guardian #1

16.

Parent / Guardian #2 Contact Information (This is the legal parent/guardian the student lives with) *

		Parent/Guardian #2 First/Last Name		Parent/Guardian #2 Mailing Address (Street/Apt. #)		Parent/Guardian #2 City		Parent/Guardian #2 State		Parent/Guardian #2 Zip Code		Parent/Guardian #2 Cell Phone Number		Parent/Guardian #2 Home/Additional Phone Number		Parent/Guardian #2 email address		Parent/Guardian #2 Place of Employment		Parent/Guardian #2 Employment Phone Number		Relationship to Student
Parent/Guardian #2

17.

Step-Parent/Guardian (1) Contact Information

		Step-Parent/Guardian (1) First/Last Name		Step-Parent/Guardian (1) Mailing Address (Street/Apt. #)		Step-Parent/Guardian (1) City		Step/Parent/Guardian (1) State		Step-Parent/Guardian (1) Zip Code		Step-Parent/Guardian (1) Cell Phone Number		Step-Parent/Guardian (1) Home/ Additional Phone number		Step-Parent/Guardian (1) email address		Step-Parent/Guardian (1) Place of Employment		Step-Parent/Guardian (1) Employment Phone Number		Relationship to Student
Step-Parent/Guardian (1)

18.

Step-Parent/Guardian (2) Contact Information

		Step-Parent/Guardian (2) First/Last Name		Step-Parent/Guardian (2) Mailing Address (Street/Apt. #)		Step-Parent/Guardian (2) City		Step/Parent/Guardian (2) State		Step-Parent/Guardian (2) Zip Code		Step-Parent/Guardian (2) Cell Phone Number		Step-Parent/Guardian (2) Home/ Additional Phone number		Step-Parent/Guardian (2) email address		Step-Parent/Guardian (2) Place of Employment		Step-Parent/Guardian (2) Employment Phone Number		Relationship to Student
Step-Parent/Guardian (2)

19.

With whom does the child being enrolled live? Mark all that apply.*

Father

Mother

Step-father

Step-mother

Guardian

Other, please specify

20.	To whom may the child be released?*

21.	Is any parent/guardian currently an active duty member of a branch of the armed forces. (Army, Navy, Marine Corps, Coast Guard) including FULL-TIME Reserve or National Guard duty. *
	Is any parent/guardian currently an active duty member of a branch of the armed forces. (Army, Navy, Marine Corps, Coast Guard) including FULL-TIME Reserve or National Guard duty. * YesNo

22.

If the student is under court order, please provide the following information from the court order.

		Court Order Information
Custody
Guardianship
Ed. Rights

23.

Is the student ordered into?

		Information
Foster Care (1305) (Yes or No)
Group Home (1306) (Yes or No)
Date:
Contact Person:
Name/address of Natural Parent (s):

24.	Is the student in a non-court ordered emergency shelter care?
	Is the student in a non-court ordered emergency shelter care? YesNo

25.

If the answer above regarding emergency shelter cares was "Yes", list the date and contact person.

Date:
Contact Person:

26.

Information about Siblings

27.

Emergency Contact Information Parents will be called first. List those who should be called when parents cannot be reached.

	First/Last Name	Relationship	Home Phone number	Cell Phone number	Other Phone number	If you are registering multiple students, can this contact be used with all students? Yes or No	If this contact is only for some of the students, list those for whom the contact may be used.
Contact #1
Contact #2
Contact #3
Contact #4
Contact #5

28.

Special Education Services

	Yes	No
Has the student received any special education services?
Does the student have a 504 Agreement
Does the student have an IEP?
Does the child receive ESL services?
Does the child receive Hearing Impaired Services?
Does the Child receive speech services?
Was the student in the process of an evaluation for Special Education services prior to registering at Muncy?

29.

List the Agency and Dates that the student received any of the following prior treatment or support services or treatments within the last two years.

	Agency	Date
Inpatient Hospitalization
Outpatient Counseling
Drug and Alcohol Treatment
Vocational Rehabilitation
Residential Placements
Group Home Services
Other

30.

Has the student been involved with any of the following agencies within the last two years?

31.

List the names of any pre-school or Head Start programs the student has attended.

School 1
School 2
School 3

32.	Has the child being enrolled ever attended kindergarten in another school district?*
	Has the child being enrolled ever attended kindergarten in another school district?* YesNo

33.	Muncy School District is increasing its use of electronic communication for both school information and student information. For this reason, it is important to have correct e-mail addresses on file. Misdirected email(s) may result in the exposure of sensitive student information to those without a legitimate educational interest in the information. In an effort to avoid misdirected emails, please indicate your preference. Indicate Choice:*
	Muncy School District is increasing its use of electronic communication for both school information and student information. For this reason, it is important to have correct e-mail addresses on file. Misdirected email(s) may result in the exposure of sensitive student information to those without a legitimate educational interest in the information. In an effort to avoid misdirected emails, please indicate your preference. Indicate Choice:* I give my permission to Muncy School District to use electronic communications for both school information and student information. I do not give my permission to Muncy School District to send student information using electronic communications. Other, please specify

34.

I would like to add the following email addresses for receiving school and student information from Muncy School District in relation to my child(ren). These are in addition to the email addresses listed in the parent/guardian information.

		#1		#2		#3
Additional email addresses:

35.	I affirm that the information provided on this application is true and accurate. I acknowledge this registration is not complete until approved by the District Administration. (Enter your name below)*

36.	Enter date of enrollment application
	mm/dd/yyyy

Completing this form is only one part of the registration process. A meeting must be scheduled with Mrs. Mary Smith before any child may begin attending school. Please call to schedule the meeting: 570-546-3125, ext. 3450. Please bring the following documents with your to the meeting:
Birth Certificate
Immunization Record
Proof of Residency (Utility Statement, Lease/Rental Agreement, Valid Drivers License, Tax Statement)
Last Report Card/High School Transcript
Custody Documentation (if applicable)
Copy of the Child's IEP (if applicable)

During the registration meeting, a Parental Registration Statement (Attachment A), a Home Language Survey(Attachment B), and an Internet Acceptable Use Policy must be reviewed and signed for each registered child.