Fillable Form 21: REGISTRATION FORM GRADES PRE(K)-12 CHARLESTON COUNTY (Charleston County School District)

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Form 21: REGISTRATION FORM GRADES PRE(K)-12 CHARLESTON COUNTY (Charleston County School District)

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B. FAMILY INFORMATION
Student’s Legal Last Name and Suffix Student's Legal First Name Student's Legal Middle Name Student's Preferred Name
Today's Date
Gender Date of Birth Is the student Hispanic or Latino? Race: (
Check all that apply
.)
Home Address Apt # City State Zip Code
Area/Neighborhood Home phone Cell phone Alternate phone
Area Code
_______-_________________
Area Code
_______-_________________
Area Code
______-_____________
Mailing Address, if different Apt # City State Zip Code
Primary Email Address Secondary Email Address
Is the current residence temporary? Is the student an unaccompanied youth? Is the student an emancipated minor?
(If yes, legal documentation must be provided.)
Is the current residence a Group Home or Residential Treatment Facility? Yes No
(If yes, enter the location below.)
Is the current residence a foster home?
Facility Name:
Does the student live outside of Charleston County but own real property in Charleston County with an assessed value of $300 or more in Charleston County?
Yes No
(If yes, provide the address of the property.)
Property Address:
A. STUDENT INFORMATION
M F Yes No American Indian or Alaskan Native Asian Black or African American
Native Hawaiian or Other Pacific Islander White
Yes No Yes No Yes No
If your child was not born in the United States, in what country was he/she born?
What date did your child first begin school in the United States?
Are there any custody issues we should be made aware of? Yes No
(If yes, legal documentation must be provided to the school.)
With whom does the student live? Both Parents Mother Only Father Only Mother & Step Parent Father & Step Parent Caseworker
Legal Guardian
(If yes, legal documentation must be provided to the school.)
Foster Mother Foster Father Other
Parent/Guardian #1 Legal Name (First, Middle, Last & Suffix) Relationship to Student
Home Phone Cell Phone Day Phone Lives with student
Area Code
_______-_________________
Area Code
_______-________________
Area Code
_______-_________________ Yes No
Home Address, if different from student's Apt # City State Zip Code
Parent/Guardian #1 Employer Work Address (Street, City, State, Zip Code)
Student Information/02-22-19
PAGE 1 OF 2
Is this Parent/Guardian employed by CCSD? Does this Parent/Guardian have custody of this student?
Yes No
(If yes, provide the following.)
Yes No
CCSD Employee No. Work Location Does this Parent/Guardian receive mailings? Yes No
PARENT/GUARDIAN MILITARY STATUS (Choose One) Neither Parent or Guardian is serving any military service
A Parent or Guardian is serving in: The National Guard but is not deployed The Reserves but is not deployed The National Guard and is currently deployed
The Reserves and is currently deployed The military on active duty but is not deployed The military on active duty and is currently deployed
A Parent or Guardian died while on active duty within the last year A Parent or Guardian was wounded while on active duty within the last year
CHARLESTON COUNTY SCHOOL DISTRICT
REGISTRATION FORM
DO NOT PURGE
Grade registering for:
GRADES PRE(K)-12
Previous grade level:
Yes No
Name of School
School Year 20 _______ - 20 _______
20
21
F. PARENT/GUARDIAN SIGNATURE
E. TRANSPORTATION INFORMATION
D. SCHOLASTIC INFORMATION
C. SIBLINGS
Sibling Name (First, Last) Date of Birth Age Grade School
Sibling Name (First, Last) Date of Birth Age Grade School
Sibling Name (First, Last) Date of Birth Age Grade School
Previous School: CCSD School Home Schooled Private School Private Preschool Program Other Public School Other Unknown
Previous School Name: City, State:
Has the student repeated a grade? Yes No
If yes, Grade(s) repeated
Has the student ever been expelled? Yes No
If yes, Grade(s) expelled
Did the student attend Kindergarten? Yes No
Does the student have any of the following designations:
(Check all that apply.)
504 Plan Gifted/Talented ESOL Migrant Student Transfer
Does the student have an Individualized Education Program (IEP)? Yes No
(If yes, specify the instructional setting.)
General Education Separate Class
Separate School Other:
Is transportation listed as a related service in the student’s IEP? Yes No
If the student has an IEP, please specify the area of disability:
(Check all that apply.)
Autism
Deaf-Blindness
Deafness
Developmental Delay
Emotional Disturbance
Hearing Impairment
Intellectual Disability
Multiple Disabilities
Orthopedic Impairment
Other Health Impairment
Specific Learning Disability
Speech or Language Impairment
Traumatic Brain Injury
Visual Impairment
Other (please specify)
How will the student get to school in the morning? AM Bus Only AM & PM Bus POV (Car Rider) Daycare Provides PM Bus Only Walker Bicycle
How will the student get home in the afternoon? AM Bus Only AM & PM Bus POV (Car Rider) Daycare Provides PM Bus Only Walker Bicycle
BY SIGNING THIS FORM, I AM CERTIFYING THAT ALL WRITTEN INFORMATION ON THIS FORM IS ACCURATE AND COMPLETE.
Signature of Parent/Guardian Date
CHARLESTON COUNTY SCHOOL DISTRICT REGISTRATION FORM
Birth Certificate Yes No SC Immunization Record Yes No Legal Guardianship/Custody Papers Yes No Out of Zone Yes No
Nonresident Yes No Chas Co property ownership Yes No Moving into Chas County Yes No Tuition Required Yes No
P/G: Picture ID Yes No Residency Affidavit Yes No Residency Verification Yes No Mail Verification Yes No
Other Head/Household: Notarized Statement Yes No Residency Verification Yes No Mail Verification Yes No
REVIEWED WITH P/G:
Home Language Survey Yes No
Scholastic Information Yes No
Records Requested: Records Received:
Cumulative File Reviewed: Teacher Assigned:
Enrollment Date: Bus Number:
NOTIFIED:
SPED Teacher 504 Coordinator
G/T Teacher ESOL Fed Programs
FOR ADMIN USE ONLY
Student’s Legal Last Name and Suffix Student's Legal First Name Student's Legal Middle Name Student's Preferred Name
Parent/Guardian #2 Legal Name (First, Middle, Last & Suffix) Relationship to Student
Home Phone Cell Phone Day Phone Lives with student
Area Code
_______-_________________
Area Code
_______-________________
Area Code
_______-_________________ Yes No
Home Address, if different from student's Apt # City State Zip Code
Parent/Guardian #2 Employer Work Address (Street, City, State, Zip Code)
Is this Parent/Guardian employed by CCSD? Does this Parent/Guardian have custody of this student?
Yes No
(If yes, provide the following.)
Yes No
CCSD Employee No. Work Location Does this Parent/Guardian receive mailings? Yes No
Student Information/02-22-19
PAGE 2 OF 2
CHARLESTON COUNTY SCHOOL DISTRICT
PRE-KINDERGARTEN (PK)
REGISTRATION
EARLY CHILDHOOD DATA COLLECTION
PAGE 1 OF 2
This form must be completed along with the Charleston County School District Registration Form by students registering for Pre-Kindergarten.
Student Name _________________________________________________________ Date of Birth __________________________
School registering for ____________________________________________________________ School Year 20 _____ - 20 _______
My child’s birth weight was below 5.5 pounds (check one): ☐ Yes ☐ No
Last year my child’s care was provided by an informal child care provider (check one):
☐ Unknown ☐ Relative ☐ Non-Relative
Last year my child’s care was provided by the following public provider (check one):
(Refer to Definitions of Child Care Providers (Public) on the back of this form.)
☐ Unknown ☐ Head Start ☐ Pre-Kindergarten
My child attended the program (check one): ☐ full day ☐ partial day ☐ unknown
Name of provider ___________________________________________________________________________________________
Last year my child’s care was provided by the following private provider ☐ Yes ☐ No
(Refer to Definitions of Child Care Providers (Private) on the back of this form.)
My child attended the program (check one): ☐ full day ☐ partial day ☐ unknown
Name of provider ___________________________________________________________________________________________
My child’s medical care is generally provided by (check one):
☐ Free Health Clinic ☐ Family Physician
☐ Emergency Room ☐ Other
The highest education level of my child’s Mother/female guardian is (check one):
☐ Associate Degree ☐ GED ☐ Master’s Degree ☐ PhD
☐ Bachelor’s Degree ☐ High School Degree ☐ No High School Diploma
Please indicate the years of formal education of the Mother/female guardian (Between 1 and 30): _________________________________
Was your child served in Head Start at any time?: ☐ Yes ☐ No
Indicate Family Income Range:
☐ 0-10,000 ☐ 10,001- 20,000 ☐ 20,001-30,000 ☐ 30,001-40,000 ☐ 40,001-50,000 ☐ 50,001-60,000 ☐ 60,001 or above
Indicate Family Literacy Years: ☐ 1 ☐ 2 ☐ 3 ☐ 4 or more ☐ None
Indicate Family Literacy Services: ☐ Both Parents ☐ Father ☐ Guardian (or Grandparent) ☐ Mother ☐ None
By signing this form, I am certifying that all written information on this form is accurate and complete.
_________________________________________________________________________ _____________________________
Parent/Guardian Signature Date
Student Information/042120
My child has the following disability (check one, if applicable):
☐ Emotional Disability ☐ Physical Disability ☐ Other
☐ Learning Disability ☐ Speech Disability
Charleston County School District | Pre-Kindergarten(PK) Registration | Early Childhood Data Collection
PAGE 2 OF 2
Student Information/042120
Full Day – A full day program is one in which students attend for 6.5 hours or more a day.
Partial Day – A partial day program is one in which students attend for less than 6.5 hours a day.
Head Start – A program of the US Department of Health and Human Services that provides comprehensive early childhood education,
health, nutrition, and parent involvement services to low income children and their families. Locate your local Head Start:
https://www.benefits.gov/benefits/benefit-details/1938
Pre-kindergarten program in a public school –
A state, district, or federally-funded, developmentally-appropriate program for 4- year
-
olds in a public school adhering to best practice, using research-based curriculum and assessment that must adhere to district and/or
federal guidelines.
Unknown – Self-explanatory
Military Child Care Centers – On-post child care centers that offer full-day, partial day, or hourly child care services to military families that
must be registered with DSS. Locate your local military child care centers: http://www.militaryonesource.mil/military-child-care-programs
Registered Faith Based – Faith based care for 13 or more children that are sponsored by a religious organization that must be registered
with DSS. Locate your local registered faith-based providers:
http://www.scchildcare.org/
Registered Family Home – A family home that provides care for up to 6 children at any given time within the home of the child care
provider that maintains a registration or license if a person provides care to more than one unrelated family of children on a regular basis
(more than four hours day or more than two days a week).
Locate your local registered family home providers: http://www.scchildcare.org/
Registered Group Home Provider – Group Homes provide care for 7 to 12 children in the home of the child care provider
. They may care
for up to 8 children without an additional caregiver. For details on registered group homes:
http://www.scchildcare.org/providers/become-
licensed/licensing-requirements/licensed-group-child-care-home.aspx
Exempt Provider –
A child care provider that operates less than 4 hours a day or less than 2 days a week or care for children from only 1
unrelated family. It is not inspected by DSS Child Care Licensing and monitored only because they volunteer for ABC Quality
. For details on
exempt providers: http://scchildcare.org/providers/become-licensed/licensing-exemptions.aspx
First Steps (CERDEP/CDEP) –
A private state-funded, income based, developmentally appropriate educa
tion program adhering to best
practice, using research-based curriculum and assessment that must adhere to DSS regulations and SCDE Guidelines. It is housed in a
private, registered child care facility. Contact your local First Steps: https://scfirststeps.org/who-we-are/local-partnerships/
1
On the registration form, you do not have to provide the specific type of private childcare; these examples are listed as reference.
Relative: Informal Child Care – Unregulated or licensed care provided by family that is not subject to regulations or formal guidelines.
Non-Relative: Informal Child Care – Unregulated or licensed care provided by another caregiver (non-relative) that is not subject to
regulations or formal guidelines.
DEFINITIONS OF FULL DAY AND PARTIAL DAY CARE
DEFINITIONS OF PUBLIC CHILD CARE PROVIDERS
DEFINITIONS OF PRIVATE CHILD CARE PROVIDERS
1
DEFINITIONS OF INFORMAL CHILD CARE
Updated August 28, 2019
Home Language Survey (HLS)
The Civil Rights Act of 1964, Title VI, Language Minority Compliance Procedures, requires school
districts and charter schools to determine the language(s) spoken in each student’s home in order to
identify their specific language needs. This information is essential in order for schools to provide
meaningful instruction for all students as outlined in Plyer v. Doe, 457 U.S. 202 (1982).
The
purpose of this survey is to determine the primary or home language of the student. This survey is
given to all students enrolled in the school district/charter school. The HLS is administered once, upon
initial enrollment in South Carolina, and should remain in the student’s permanent record.
If
a language other than English is recorded for ANY of the survey questions below, the appropriate
identification screening assessment will be administered to determine whether or not the student qualifies
for additional English language development support.
Please answer the following questions:
1. What is the language that the student first acquired? ________________________________
2. What language(s) is spoken most often by the student? __________________________
3. What is the primary language used in the home, regardless of the language spoken by the
student? __________________________
*4. In what language do you wish to have communication from the school? ___________________
Student Name: __________________________________________ Grade: _____________
Parent/Guardian Name: ________________________________________
Parent/Guardian Signature: _____________________________________ Date: __________
Your signature above certifies that you understand if a language other than English has been identified, your student will be
tested to determine if they qualify for English language development services, to help them become fluent in English. If entered
into the English language development program, your student will be entitled to services as an English learner and will be tested
annually to determine their English language proficiency.
Name: ___________________________________________________ Date: ___________
For School Use Only:
School personnel who administered and explained the HLS and the placement of a student into an
English language development program if a language other than English was indicated
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Form 21: REGISTRATION FORM GRADES PRE(K)-12 CHARLESTON COUNTY (Charleston County School District)

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Completed 13 February 2021

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