Student Enrollment Form

Student Enrollment Form STUDENT NAME (MUST MATCH BIRTH CERTIFICATE) Student Last Name Student First Name Student Middle Name Student s Preferred Name For Office Use Only Birth Cert Immunization Soc Sec Card Custody Proof of Address Withdrawal/Report Card AM Bus: PM Bus: Has the Student Ever Been Enrolled in Cleveland City Schools Before? Does the Student Have Siblings Already Enrolled in Cleveland City Schools? Has the Student Ever Been Enrolled in a Tennessee Public School? If Not Already Listed Above, Please List the Student s Last School Name, City, and State Yes No Yes No Yes No PREVIOUS SCHOOL ENROLLMENT If Yes, When/Where? If Yes, Please List Their Names/Schools. If Yes, When/Where? STUDENT DEMOGRAPHICS Gender Male Female Birthdate Grade Level Did Student Receive Special Services at Previous School? Yes No Social Security Number List Any Legal Alerts to be Included in Student s File BIRTH INFORMATION (REQUIRED BY STATE OF TENNESSEE) Mother s Maiden Name Student s Birth City Student s Birth State Student s Birth County Student s Birth Country Where does your student stay at night? RESIDENCY INFORMATION (REQUIRED BY STATE OF TENNESSEE) Home/Apartment Owned/Rented by Parent/Guardian Shelter Campsite With Relative/Friend (Family Does Not Have a Residence) Motel Automobile Inadequate Housing (No Electricity/Running Water) Other (Explain):

OTHER STUDENT INFORMATION Student s Primary Phone # Student s Email Address Student s Primary Physical Address Zoning for this Address In Zone Out of Zone CCS Employee Will Student Ride Bus? AM PM Both Will Not Ride List Any Medical Alerts to be Included in Student s File Student s Ethnicity Latino/Hispanic Not Latino/Hispanic Student s Race (Check All That Apply) American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Pacific Islander White PRIMARY STUDENT CONTACT (ADDITIONAL CONTACTS SHOULD BE ADDED THROUGH PARENTCONNECTXP) Primary Contact Name Relationship to Student Lives with Student? Yes No Custody ( Primary or Joint) of Student? Yes No Contact for Student Emergency? Yes No Can Pick Up Student? Yes No Email Address ( Send Automated Messages/Notifications) Primary Phone Number ( Send Automated Messages/Notifications) Cell Phone Number ( Send Automated Messages/Notifications) Work Phone Number ( Send Automated Messages/Notifications) Contact s Address Same As Student (Do Not Fill Out) Parent/Guardian Signature Date

Contact Form for Parents without Internet Access Once a primary contact is entered into the CCS Data System and processes overnight, that parent may then log into ParentConnectXP and add/edit additional contacts and their access to the student(s). Please contact your student s school for information on logging in to the ParentConnectXP system. Arnold Elementary, (423) 472-2241 Blythe/Bower Elementary, (423) 479-5121 Cleveland High School, (423) 478-1113 Cleveland Middle School, (423) 479-9641 Mayfield Elementary School, (423) 472-4541 Ross Elementary School, (423) 479-7274 Stuart Elementary School, (423) 476-8246 Teen Learning Center, (423) 339-0902 Yates Primary School, (423) 479-1723 If a parent does not have access to a computer with Internet access, you may fill out the form below and return it to your child s school. If a child has siblings in other Cleveland City schools, only one form is need to update all records. Student Name Primary Contact Name STUDENT INFORMATION Siblings in CCS (with school in parentheses) Primary Contact Name Relationship to Student ADDITIONAL CONTACT #1 Lives with Student? Yes No Custody ( Primary or Joint) of Student? Yes No Contact for Student Emergency? Yes No Can Pick Up Student? Yes No Email Address ( Send Automated Messages/Notifications) Primary Phone Number ( Send Automated Messages/Notifications) Cell Phone Number ( Send Automated Messages/Notifications) Work Phone Number ( Send Automated Messages/Notifications) Contact s Address Same As Student

ADDITIONAL CONTACT #2 Primary Contact Name Relationship to Student Lives with Student? Yes No Custody ( Primary or Joint) of Student? Yes No Contact for Student Emergency? Yes No Can Pick Up Student? Yes No Email Address ( Send Automated Messages/Notifications) Primary Phone Number ( Send Automated Messages/Notifications) Cell Phone Number ( Send Automated Messages/Notifications) Work Phone Number ( Send Automated Messages/Notifications) Contact s Address Same As Student Primary Contact Name Relationship to Student ADDITIONAL CONTACT #3 Lives with Student? Yes No Custody ( Primary or Joint) of Student? Yes No Contact for Student Emergency? Yes No Can Pick Up Student? Yes No Email Address ( Send Automated Messages/Notifications) Primary Phone Number ( Send Automated Messages/Notifications) Cell Phone Number ( Send Automated Messages/Notifications) Work Phone Number ( Send Automated Messages/Notifications) Contact s Address Same As Student

Home Language Survey Student Name School ENGLISH Students whose native language is NOT English will be tested for inclusion in the ESL Program. What is the First Language Your Child Learned to Speak? What Language Does Your Child Speak Most Often Outside of School? What Language do People Usually Speak in Your Child s Home? Was the Student Born in the U.S.? Yes (Skip Remaining Questions) No (Answer Remaining Questions) Is the Student a U.S. Citizen? Yes No When Did the Student Enter the U.S.? When Did the Student Start School in the U.S.? Nombre del Alumno Escuela ESPAÑOL Se evaluarán a los estudiantes que no tengan inglés como su idioma primaria para inclusión en el programa de ESL. Cuál es la primera lengua que su niño aprendió a hablar? Cuál lengua habla su niño más frecuentemente afuera de la escuela? Cuál lengua hablan la gente generalmente en la casa de su niños? Nació su niño en Estados Unidos? Si (No responder las preguntas restantes) No (Responda a las preguntas que quedan) Es el estudiante un ciudadano de Estados Unidos? Si No Cúando entró el estudiante en Estados Unidos? Cuándo el estudiante comenzar la escuela en los Estados Unidos? Parent/Guardian Signature (Firma del Padre) Date (Fecha)

Student Records Request SCHOOL REQUESTING RECORDS Arnold Elementary School Mr. Mike Chai, Principal 473 8 th Street NW Cleveland, TN 37311 Voice: (423) 472-2241 Fax: (423) 472-9877 Blythe/Bower Elementary School Dr. Joel Barnes, Principal 604 20 th Street SE Cleveland, TN 37311 Voice: (423) 479-5121 Fax: (423) 472-2459 Cleveland High School Mrs. Autumn O Bryan, Principal 850 Raider Drive NW Cleveland, TN 37312 Voice: (423) 476-1832 Fax: (423) 478-5865 Cleveland Middle School Mr. Mike Collier, Principal 3635 Georgetown Road NW Cleveland, TN 37312 Voice: (423) 479-9641 Fax: (423) 479-9553 Mayfield Elementary School Mr. Kelly Kiser, Principal 501 20 th Street NE Cleveland, TN 37312 Voice: (423) 472-4541 Fax: (423) 472-2539 Ross Elementary School Mrs. Lisa Earby, Principal 4340 Mouse Creek RD NW Cleveland, TN 37312 Voice: (423) 479-7274 Fax: (423) 472-9763 Stuart Elementary School Mr. Randy Stephens, Principal 802 20 th Street NW Cleveland, TN 37311 Voice: (423) 476-8246 Fax: (423) 479-5016 Teen Learning Center Mrs. Barbara Ector, Principal 350 Central Avenue NW Cleveland, TN 37311 Voice: (423) 339-0902 Fax: (423) 559-9477 Yates Primary School Mrs. Carolyn Ingram, Principal 750 Mouse Creek RD NW Cleveland, TN 37312 Voice: (423) 479-1723 Fax: (423) 472-2388 STUDENT INFORMATION AND RELEASE SIGNATURE Student Name Parent/Guardian Name Grade Level Birth Date Previous School s Name Previous School s Address Previous School s Phone Number Previous School s Fax Number I hereby authorize the release of a complete copy of my student s records to Cleveland City Schools for the purpose of enrollment. Please fax copies of all academic, health-related, and special services records to the number for the school checked above. Parent/Guardian Signature NOTE: Parental permission is no longer required when records are requested by authorized school personnel in compliance with "Federal Education Rights & Privacy Act, Final Rule on Educational Records, Federal Register, June 17, 1976, Volume 41, No. 118, Page 24675." Date

ENGLISH Migrant Education Program Occupational Survey STATE OF TENNESSEE DEPARTMENT OF EDUCATION BILL HASLAM 6 th FLOOR, ANDREW JOHNSON TOWER KEVIN HUFFMAN GOVERNOR 710 JAMES ROBERTSON PARKWAY COMMISSIONER NASHVILLE, TN 37243-0375 Student Information: Last Name First Name Gender Race School: Grade: Year: Migrant students may be eligible for additional services and assistance. Please answer the following questions and return the survey to the school so that we can determine if your child qualifies for migrant services. 1. Did you or someone in your family come to Tennessee looking for temporary or seasonal work in agriculture, fishing, dairy, or in any plant processing foods (examples: working with tobacco, tomatoes, cotton, strawberries, nurseries, trees, pork, chickens, vegetables, etc)? YES NO If yes, please mark which member of the family does or did this kind of work: Mother Father Children Other 2. Do you or someone in your family currently work in agriculture fishing, dairy, or in any plant processing foods (examples: working with tobacco tomatoes, cotton, strawberries, nurseries, trees, pork, chicken, vegetables, etc). YES NO If yes, please mark which member of the family does this kind of work: Mother Father Children Other 3. If your current job is not temporary work in agriculture or fishing, did you or someone in your family work in a temporary or seasonal agriculture of fishing in the last 3 years? YES NO If yes, where? City State Country If you answered yes to any of the questions above, please answer questions 4 and 5. 4. What is your current address? 5. What is your current telephone number? NOTE TO THE LEA: PLEASE RETURN COMPILED SURVEYS TO JESSICA CASTANEDA 4660 HILLS CREEK ROAD, MCMINNVILLE TN 37110 CALL 931-668-4139 IF YOU HAVE QUESTIONS TN form #ED-5438

SPANISH STATE OF TENNESSEE DEPARTMENT OF EDUCATION BILL HASLAM 6 th FLOOR, ANDREW JOHNSON TOWER KEVIN HUFFMAN GOVERNOR 710 JAMES ROBERTSON PARKWAY COMMISSIONER NASHVILLE, TN 37243-0375 Programa de Educación para Estudiantes Migrantes Encuesta Ocupacional Nombre del Estudiante: Nombre Apellido Sexo Raza Escuela: Grado: Aňo El Programa de Educación para estudiantes migrantes a través del Departamento de Educación Pública del Estado provee servicios de apoyo a los niños y familias que se han mudado Tennessee en los últimos 3 años. Para calificar en el programa las familias deben de haberse mudado de un lugar a otro en busca de trabajo temporal en agricultura o pesca. El Programa registra a niños y jóvenes entre las edades de 3 a 21 años (asistan o no a la escuela). Agradecemos que nos ayuden a determinar si su niňo o pariente califica para recibir servicios en este programa. Por favor, conteste las siguientes preguntar y entréguelas a la escuela. 1. Vino usted o alguien en su familia a buscar trabajo temporal en agricultura o en el campo (ejemplo: tabaco, papas, algodón, fresas, viveros, trabajo con árboles, etc.), o de pesca (empacadora de pescados o mariscos) o alguna planta procesadora de alimentos (cerdos, pollos, vegetales, etc.)? SI NO Si su contestación es si por favor indique que miembro de su familia hizo esta clase de trabajo. Madre Padre Hijos Otros 2. Ud. o alguien de su familia trabaja ahora en agricultura (ejemplos : tabaco, papas, algodón, fresas, viveros, trabajo con árboles, etc. ) o en una procesadora de pescado, lechería, o procesando comida (puerco, pollo, vegetales, etc.) SI NO Si su contestación es si por favor indique que miembro de su familia trabaja en esta clase de trabajo. Madre Padre Hijos Otros 3. Hace cuánto tiempo se mudó a este condado? Mes Año 4. Si su trabajo actual no se relaciona a la agricultura y pesca, Usted o algún miembro de su familia ha trabajado en dichas actividades en los últimos 3 aňos? SI NO Dónde? Ciudad Estado País 5. Cuál es su dirección actual? Ciudad Código Postal Teléfono 6. Cuál es su numero del teléfono actual? NOTE TO THE LEA: PLEASE RETURN COMPILED SURVEYS TO JESSICA CASTANEDA 4660 HILLS CREEK ROAD, MCMINNVILLE TN 37110 CALL 931-668-4139 IF YOU HAVE QUESTIONS