Water Valley School District 2017-2018 Residency & Registration Form

Entered By ______ Date: __________

Student Information: First Name: ______________________________ Middle: ______________ Last: ________________________ Preferred name: _____________________________________ Date of Birth: _________________ Age: _____ Grade: _____ Gender: Male Female

Race: White Black Hispanic Native American Asian Pacific Islander Multi Other ________ Student Cell Phone: __________________________ Student Social Security Number: ____________________ Transportation Method: Car Rider Bus Rider – Bus # _________ In the event of an emergency early dismissal, how should the student be

dismissed? Please provide name, address, phone, and/or bus #:

____________________________________________________________________________________

____________________________________________________________________________________ Previous School Attended (if other than Davidson Elementary or Water Valley High School): _____________________________________________________ City ____________________ State ________ Has this student ever been suspended/expelled from school? Yes No

Are there any custody issues regarding this student? Yes No

If yes, please explain and provide copies of supporting court documents. __________________________________________________________________________________________ Has this student participated in resource classes? (Gifted, Special Education, Speech, etc.) If so, please list: __________________________________________________________________________________________

_____ YES _____ NO The student listed above has permission to go on class field trips by bus.

_____ YES _____ NO The student listed above has permission to be included on the WVSD website.

Signature of parent/guardian: ________________________________________________ Date: ________________

Parent/Guardian 1

Parent/Guardian 1 Name: ____________________________________________________________________

Relationship: Mother Father Guardian: Relationship _____________________________

** Legal guardianship papers will need to be provided if you are not the student’s parent.

Parent/Guardian Physical Address:

Street: __________________________________________________________________

City: ________________________________________ State: ______ Zip: ____________

Parent/Guardian Mailing Address: Same as physical address

Street: __________________________________________________________________

City: ________________________________________ State: ______ Zip: ____________

Parent/Guardian 1 Phone Contacts:

Home: ______________________________________ Use this number for automated calls

Cell: ________________________________________ Use this number for automated calls

Work: ______________________________________ Used only in case of emergency

Parent/Guardian 1 E-Mail: ____________________________________________________________________

Parent/Guardian 1 Employer: _________________________________________________________________

Parent/Guardian 2

Parent/Guardian 2 Name: ____________________________________________________________________

Relationship: Mother Father Guardian: Relationship _____________________________

** Legal guardianship papers will need to be provided if you are not the student’s parent.

Parent/Guardian Physical Address:

Street: __________________________________________________________________

City: ________________________________________ State: ______ Zip: ____________

Parent/Guardian Mailing Address: Same as physical address

Street: __________________________________________________________________

City: ________________________________________ State: ______ Zip: ____________

Parent/Guardian 2 Phone Contacts:

Home: ______________________________________ Use this number for automated calls

Cell: ________________________________________ Use this number for automated calls

Work: ______________________________________ Used only in case of emergency

Parent/Guardian 2 E-Mail: ____________________________________________________________________

Parent/Guardian 2 Employer: _________________________________________________________________

Water Valley School District

Residency Registration and Documentation Checklist TO BE COMPLETED BY PARENT, GUARDIAN OR OTHER ADULT

Name of Parent, Guardian or Other Adult: _______________________________________________________

Parent/Guardian/Other Adult PHYSICAL Address: __________________________________________________

__________________________________________________ (A post office box number is NOT acceptable)

List each student attending Water Valley School District and give their grade level:

Student Grade

I hereby certify the information given above on this form is a true and correct statement of my legal residence. Should any legal residence change while the above listed students are enrolled in Water Valley School District, I will promptly notify the appropriate officials of the school district. Further, I understand a pupil is not legally enrolled until this form is completed and signed by the parent, guardian, or other adult with whom the student may be living. I understand a pupil admitted under false information is not legally enrolled and is subject to penalty.

_____________________________________________ ___________________ _________________________ Signature of Parent, Guardian or Other Adult Date Telephone Number

TO BE COMPLETED BY THE SCHOOL DISTRICT Documents provided to me by Parent/Guardian/Other Adult: (Minimum of 2 required)

1. ___ Filed Homestead Exemption Application Form/Land Tax Receipt (Must be from current year) 2. ___ Mortgage Documents/Property Deed (mortgage documents must indicate current year, if property deed used,

physical address must appear on the deed) 3. ___ Apartment or Home Lease (cannot be handwritten receipt and must be in current year) 4. ___ Utility Bills (must be within the last three months prior to registration – no cell phone or cable

bills) Acceptable bills: light, gas, water, landline phone 5. ___ Automobile Registration (for current vehicle tag – not car title) 6. ___ Valid Driver’s License or State issued identification 7. ___ Any other documentation that will be objectively and unequivocally establish the parent or legal guardian

resides within the school district as determined by the principal, superintendent or designee. 8. ___ Student is living with legal guardian – (LEGAL CUSTODY DOCUMENT) a copy of the court order appointing the

guardian must be provided to the district. If a petition of guardianship has been filed and the decree is pending, the student or guardian must provide a certified copy of the filed petition for guardianship.

Date: ___________________ Representative – School District: ______________________________________

Water Valley School District Home Language Survey Because the Water Valley School District is unaware of all English Language Learners the Mississippi Department of

Education recommends that schools conduct a survey of language used in the home. Please complete this survey and return it to the school.

Child’s Name: _____________________________ Parent’s Name: ____________________________________

Does your child speak any language other than English? Yes No

If YES, please answer the following questions:

1. What was the first language your child learned to speak? _________________________________________ 2. Have you and/or your child ever lived in another country? _______ If yes, what country? _______________ 3. Has your child ever attended school in another country? _______ If yes, what country? _________________

What grades? ___________ When did your child enroll in school in the United States? _______________ 4. Has your child ever received English Language Learner instruction? ______________ 5. What language does your child speak most often? _______________________________________________ 6. What language is most often spoken in your home? _____________________________________________

Water Valley School District Corporal Punishment

Student’s Name (Print): __________________________________________________________ Grade: ______

___________________________________ _______________________________________ _______________ PRINT Parent/Guardian name SIGNATURE of Parent/Guardian Date

_____ I AGREE for my child to receive corporal punishment (spanking) while at school.

_____ I DO NOT AGREE for my child to receive corporal punishment (spanking) while at school. I understand it is the responsibility of my child to remind the teacher/administrator that his/her parent/guardian does not want him/her to receive corporal punishment (spanking) while at school.

FOR OFFICE USE ONLY MSIS # ______________ Enrollment Date: ___________ Bus # _________ Homeroom Teacher: ____________ Check when complete/received/verified or if applies:

__ Birth Certificate __ Social Security Card __ Homeless __ Verification of Legal Residence (2) __ ACTIVE PARENT __ Limited English Proficient __ Form 121 __ IEP __ Migrant/Immigrant __ Registration Form __ Home-Language Survey __ SAM Data entry Completed

__ Corporal Punishment

Water Valley School District 2017-2018 Student Health Information Form

PLEASE PRINT Student __________________________ Age____ Grade_____ DOB _____ Parent/Legal Guardian __________________________________________ Address ______________________________________________________ Mom-Work # _________________ Cell#___________ Home#___________ Dad-Work# _____________Cell# ________________ Home# ____________ List 2 additional emergency contacts in the event the parent/guardian can’t be reached. These contacts will assume responsibility for your child. Name____________________________ Phone#(s) ____________________ Name____________________________Phone#(s) ____________________ Important Reminder: In the event your contact information should change, or the health status of your child should change, it is the responsibility of the parent or guardian to contact the school nurse. I give permission for the school nurse to contact my child’s physician concerning medications or health problems pertaining to my child. Physician’s Name___________________ Office # _______________ Parent/Guardian __________________________________________ Permission to Administer Over-the-Counter Medications I give permission for the administration of the following medications to my son/daughter in the event of headache, fever, minor cuts, stomachache, or any minor medical problem. __Tylenol __Cough drops __Calamine lotion __Hydrocortisone Cream __Ibuprofen __Tums __Children’s Pepto __Burn Cream __Benadryl __Oral-gel __Visine Eye drops __Chloraseptic spray __Neosporin Medical History Please check those that apply to your son/daughter: __Diabetes ____Seizures ____Asthma ___ADD/ADHD __Fainting __Head injury ___Stomach problems ___High blood pressure __Hearing Loss __Takes breathing treatments __Shortness of breath __Blood disorders (Specify) __Wears glasses/contacts __Heart problems __Headaches/migraines __Cancer (Specify) __Other health problem (Specify) ________________________________________________ ALLERGIES- If your child has an allergy or a history of anaphylaxis, have your doctor fill out an Allergy Action Plan. This includes an allergy to foods, insects, grass, unknown, etc. Please see the school nurse to set up a plan of care for your child. ASTHMA- If your child has a diagnosis of asthma, have your doctor fill out an Asthma Action Plan. This is a State Law and must be updated each school year. Surgeries/Bone Fracture- Has your child had any surgeries or broken bones? If so, explain. ________________________________________________________________________________________________________________________________________________________ MEDICATIONS- Does your child take any medications on a regular basis? __ Yes __No Please list names of medications, amount taken, time taken, and physician’s name: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please list sibling name and grade below: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________ PARENT SIGNATURE/DATE ________________________________________________

Water Valley School District DES: Hope Shaw, RN WVHS: Debra Beckwith, RN

Water Valley School District requires all students who need medication during school hours must do the following in order to receive prescribed medications at school:

1. You must present a written consent form that is signed by a parent/guardian and is filled out by your

child’s doctor. These are the regulations set by the MS Department of Education and the MS School

Nurse Association. No prescribed medications will be given without a consent form signed and on file

in the nurse’s office.

2. ALL medications must be brought to the school by the parent/guardian in the original prescription

bottle. Tell your pharmacist you need a labeled bottle for school use. Do not send medications with

the student in a baggie, paper towel, Etc. They will not be given! Students are not allowed to

transport any medications. Parents must bring all medications to the school. These are the

regulations set by MDE and the MS School Nurse Association. It is the Law. This is to ensure the safety

of your child and other students.

3. Medications that can be taken at home before or after school hours must be taken at home. Only

medications that are required during school hours will be given at school. Most ADD/ADHD

medications can be taken at home before school begins unless otherwise instructed by your doctor.

I give the school nurse, Hope Shaw, RN, or Debra Beckwith, RN, permission to give prescribed medications to my child as prescribed by his/her doctor. In the event the school nurse is out or the student is on a field trip, I give permission for trained office staff or a trained teacher to give the prescribed medication. ____YES __NO I understand if I mark NO, the medication will not be given. The parent/guardian will need to come to the school to give the medication, and make arrangements of how & when the medication will be given on a field trip. Name of Student _________________________________________ Grade _____________ Parent/Guardian Signature _________________________________ Date ______________

Water Valley School District

Active Parent Online Registration Form

NEW USERS/LOST or FORGOTTEN ACCOUNT/ADD NEW STUDENT

_____ I am a NEW USER and request to be an ACTIVE PARENT and view the information made available to

me for the following student(s).

Parent/Guardian Name: ______________________________________________________________________

E-Mail Address: _____________________________________________________________________________

Identification: ___________________ (LAST 4 DIGITS OF PARENT’S SOCIAL SECURITY NUMBER)

_____ I already have an ACTIVE PARENT account and would like to add another child to my account.

List all students you have in the Water Valley School District on one form. You DO NOT have to fill out a form

at each school.

Student(s) Name (PRINT) Grade School (DES or WVHS)

Parents – you MUST provide the Username and the Password!

Parent/Guardian Username Information Your USERNAME will be your last name and the last 4 digits of your Social Security Number.

Your PASSWORD has to be at least 4 letters and 2 numbers.

USERNAME: PASSWORD:

Parent/Guardian Signature: ______________________________________________ Date: ________________

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(FOR OFFICE USE ONLY)

Yes

No I authorize the release of the child’s record. I have verified the child’s parent/guardian has been approved

to view his/her records and be registered as an ACTIVE PARENT.

School Official: ________________________________________________________ Date: ________________

Water Valley School District

Transportation Department Bus Privilege Application

2017-2018

One form per student, filled out completely – multiple students on one form IS NOT acceptable.

Student Name (PRINT): _______________________________________ Nickname: ______________________

Age: ______ Grade (2016-2017 year): ______ Homeroom Teacher (DES): _____________________________

Parent/Guardian Name (PRINT): _______________________________________________________________

Parent/Guardian Emergency Number(s):

Cell ____________________________ Home ________________________ Work _______________________

(Contact anytime) (Contact anytime) Contact time? ________________

Parent/Guardian E-Mail Address: _______________________________________________________________

Preferred method of contact from a transportation team member: __ phone call __ text message __ e-

mail Does this child have any special needs? _____ yes _____ no (example: wheelchair, seizures, etc.)

If yes, please explain:

__________________________________________________________________________________________

__________________________________________________________________________________________

Morning Pick – Up Address: ___________________________________________________________________

Afternoon Drop – Off Address: _________________________________________________________________

I agree to abide by the rules set forth in the Water Valley School District Handbook and by the rules and laws set forth by the Mississippi Department of Education. I understand failure to obey the rules will result in a write up and consequences set forth by the Water Valley School District, which are listed in the Student Handbook and Code of Conduct. I understand riding a school bus is a privilege, not a right, and that privilege can and will be taken away if a student cannot or will not obey the rules.

**Students will ONLY be transported to and from the addresses listed above. Any changes must be made

through the office of your child’s school**

Parent/Guardian Signature: ________________________________________________ Date: ______________

Student’s Signature: ______________________________________________________ Date: ______________

(BOTH signatures required)

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(OFFICE USE ONLY)

Assigned bus morning _______________________________________________ stop number______________

Assigned bus afternoon ______________________________________________ stop number _____________

Approved by ___________________________________________________