Fillable Form 725110.1: CHARLOTTE-MECKLENBURG SCHOOLS

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Form 725110.1: CHARLOTTE-MECKLENBURG SCHOOLS

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CHARLOTTE-MECKLENBURG SCHOOLS
PROCEDURES FOR ENROLLMENT
12/2017
Form 725110.1
Page 1 of 6
7/2014
Enrollment forms may be submitted to Student Placement - Smith Family Center, to any CMS school or any
CMS Learning Community Office. After the enrollment deadline for the second lottery, students must submit
enrollment forms directly to their home schools. (Lottery dates are available on the Student Placement and
Magnet sections of the CMS website.)
In compliance with North Carolina law, students must be 5 years of age on or before August 31 to be
considered for Kindergarten. Students applying for any Pre-K program must be 4 years of age on or before
August 31.
The following documents are required for enrollment:
Student Enrollment Form
Proof of date of birth and legal name (see page 2)
Proof of Residency (see page 2)
Safe Schools Declaration
Current Immunization Record*
All children entering NC public schools for the first time must submit proof of a
Health Assessment.*
*These documents are required upon student entry. A “30 calendar day grace period” for submission is
granted for students not having required documentation.
For more information contact the following:
• Guardianship questions should be directed to Student Placement at 980-343-5335.
• Questions about students with special needs should be directed to the Programs for
Exceptional Children at ec@cms.k12.nc.us or 980-343-6960.
• Students whose primary language is not English should contact the International
Center at ic@cms.k12.nc.us or 980-343-3784.
Student Placement is located at
1901 Herbert Spaugh Lane, Charlotte NC 28208
Programs for Exceptional Children is located at
4421 Stuart A
ndrew Boulevard, Charlotte, NC 28217
The International Center is located at
4000 Applegate Road, Charlotte NC 28209
Page 1 of 6
Page 1 of 6
CHARLOTTE-MECKLENBURG SCHOOLS
7/2014
Form 725110.1
REQUIREMENTS FOR ENROLLMENT
Before any student is assigned to attend Charlotte-Mecklenburg Schools (CMS), the student’s parent, legal guardian or sponsor
(legal guardianship or sponsorship requires additional documentation from a court or agency) must provide proof of date of birth,
proof of legal name, proof of legal residence in Mecklenburg County, current immunizations, and NC Health Assessment for
students new to a NC public school.
For Proof of Date of Birth and Legal Name
One (1) of the following documents must be shown:
Original or photocopy of birth certificate
Passport
State-issued identification document
US Department of State (I-94 Arrival/Departure
Record)
Refugee resettlement letter (Local sponsoring
agency, US Department of Health and Human Services,
Office of Refugee Resettlement) Questions? Call the
International Center at 980-343-3784
Decree of Adoption
Student’s driver’s license
Life insurance policy
A certified copy of any medical record of the child's
birth issued by the treating physician or the hospital in
which the child was born
A certified copy of a birth certificate issued by a
church, mosque, temple, or other religious institution
that maintains birth records of its members
Previously verified school records
ONE (1) document from one of the following columns:
ONE (1) of the following documents must be shown:
Letter from approved agency (group home)
Refugee resettlement letter
Copy of Charlotte Housing Authority lease
These documents are for address verification and must reflect the current address for enrollment or change of address. CMS has an
appeal process for families who have difficulty verifying proof of residency, so students can be enrolled without unnecessary delay. Call
Student Placement at 980-343-5335 or the International Center at 980-343-3784 for more information.
This residency policy does not apply to homeless students, as defined by the McKinney---Vento Act.
For more information visit www.cms.k12.nc.us, email student.placement@cms.k12.nc.us or call 980‐343‐5335
For Proof of Residency
ONE (1) of the following documents must be shown:
most
AND
Current Vehicle Registration
Dated within the Past Year
o
o
o
W-2
OR
CHARLOTTE-MECKLENBURG SCHOOLS
REQUIREMENTS FOR ENROLLMENT
CHARLOTTE-MECKLENBURG SCHOOLS
Form 7251001 REQUIREMENTS FOR ENROLLMENT
BeforeanystudentisassignedtoattendCharlotteMecklenburgSchools(CMS),thestudent’sparent,legalguardianorsponsor
(legalguardianshiporsponsorshiprequiresadditionaldocumentationfromacourtoragency)mustprovideproofofdateofbirth
andlegalnameandlegalresidenceinMecklenburgCounty.
ForProofofDateofBirthandLegalName
One(1)ofthefollowingdocumentsmustbeshown:
Originalorphotocopyofbirthcertificate
Passport
Stateissuedidentificationdocument
US Department of State (I94 Arrival/Departure
Record)
Refugeeresettlementletter(Localsponsoring
agency,USDepartmentofHealthandHumanServices,
OfficeofRefugeeResettlement)Questions?Callthe
InternationalCenterat9803433784
DecreeofAdoption
Student’sdriver’slicense
Lifeinsurancepolicy
Acertifiedcopyofanymedicalrecordofthechild's
birthissuedbythetreatingphysicianorthehospitalin
whichthechildwasborn
Acertifiedcopyofabirthcertificateissuedbya
church,mosque,temple,orotherreligiousinstitution
thatmaintainsbirthrecordsofitsmembers
Previouslyverifiedschoolrecords
ForProofofResidency
ONE(1)ofthefollowingdocumentsmustbeshown:
Copy of residential deed OR record of most
recentresidentialmortgagestatement
NotarizedResidencyaffidavitfrom
homeowner
/leaseholderaffirmingtenancy
Copyofresidentiallease
HUDclosingstatement
AND
ONE(1)documentfromoneofthefollowingcolumns:
AnyONEutilitybillorworkorderdatedwithinthepast
30Days,including:gas,water,electric,telephone,or
cable
Valid North Carolina Driver’s License OR Valid North
CarolinaIdentificationCARD
Datedwithinthepast30days
o PayrollStub
o BankStatement
o CreditCardStatement
CurrentVehicleRegistration
DatedwithinthePastYear
o VehicleTaxBill
o PropertyTaxBill
o W2
o MedicaidCard
OR
ONE(1)ofthefollowingdocumentsmustbeshown:
Letterfromapprovedagency(grouphome)
Refugeeresettlementletter
CopyofCharlotteHousingAuthoritylease
Thesedocumentsareforaddressverificationandmustreflectthecurrentaddressforenrollmentorchangeofaddress.CMShasan
appealprocessforfamilieswhohavedifficultyverifyingproofofresidency,sostudentscanbeenrolledwithoutunnecessarydelay.Call
StudentPlacementat9803435335ortheInternationalCenterat9803433784formoreinformation.
Thisresidencypolicydoesnotapplytohomelessstudents,asdefinedbytheMcKinneyVentoAct.
Formoreinformationvisitwww.cms.k12.nc.us,emailstudent.placement@cms.k12.nc.usorcall9803435335
Every Child. Every Day. For a Better Tomorrow.
CHARLOTTE-MECKLENBURG SCHOOLS
Form 7251001 REQUIREMENTS FOR ENROLLMENT
BeforeanystudentisassignedtoattendCharlotteMecklenburgSchools(CMS),thestudent’sparent,legalguardianorsponsor
(legalguardianshiporsponsorshiprequiresadditionaldocumentationfrom acourt oragency) must provideproofofdateofbirth
andlegalnameandlegalresidenceinMecklenburgCounty.
ForProofofDate ofBirthandLegalName
One(1)ofthefollowingdocumentsmustbeshown:
Originalor photocopyofbirthcertificate
Passport
Stateissuedidentificationdocument
US Department of State (I94 Arrival/Departure
Record)
Refugeeresettlementletter(Localsponsoring
agency,USDepartmentofHealthandHumanServices,
OfficeofRefugeeResettlement)Questions?Callthe
InternationalCenterat9803433784
DecreeofAdoption
Student’sdriver’slicense
Lifeinsurancepolicy
Acertifiedcopyofanymedicalrecordofthechild's
birthissuedbythetreatingphysicianorthehospitalin
whichthechildwasborn
Acertifiedcopyofabirthcertificateissuedbya
church,mosque,temple,orotherreligiousinstitution
thatmaintainsbirthrecordsofitsmembers
Previouslyverifiedschoolrecords
ForProofofResidency
ONE(1)ofthefollowingdocumentsmustbeshown:
Copy of residential deed OR record of most
recentresidentialmortgagestatement
NotarizedResidencyaffidavitfrom
homeowner
/leaseholderaffirmingtenancy
Copyofresidentiallease
HUDclosingstatement
AND
ONE(1)documentfromoneofthefollowingcolumns:
AnyONEutilitybillorworkorderdatedwithinthepast
30Days,including:gas,water,electric,telephone,or
cable
Valid North Carolina Driver’s License OR Valid North
CarolinaIdentificationCARD
Datedwithinthepast30days
o PayrollStub
o BankStatement
o CreditCardStatement
CurrentVehicleRegistration
Datedwithin thePast Year
o VehicleTaxBill
o PropertyTaxBill
o W2
o MedicaidCard
OR
ONE(1)ofthefollowingdocumentsmustbe shown:
Letterfromapprovedagency(grouphome)
Refugeeresettlementletter
CopyofCharlotte HousingAuthoritylease
Thesedocumentsareforaddressverificationandmustreflectthecurrentaddressforenrollmentorchangeofaddress.CMShasan
appealp
rocessforfamilieswhohavedifficultyverifyingproofofresidency,sostudentscanbeenrolledwithoutunnecessary delay.Call
StudentPlacementat9803435335ortheInternationalCenterat9803433784formoreinformation.
Thisresidencypolicydoesnotapplytohomelessstudents,asdefinedbytheMcKinneyVentoAct.
Formoreinformationvisitwww.cms.k12.nc.us,emailstudent.placement@cms.k12.nc.usorcall9803435335
Every Child. Every Day. For a Better Tomorrow.
CHARLOTTE-MECKLENBURG SCHOOLS
Form 7251001 REQUIREMENTS FOR ENROLLMENT
BeforeanystudentisassignedtoattendCharlotteMecklenburgSchools(CMS),thestudent’sparent,legalguardianorsponsor
(legalguardianshiporsponsorshiprequiresadditionaldocumentationfromacourtoragency)mustprovideproofofdateofbirth
andlegalnameandlegalresidenceinMecklenburgCounty.
ForProofofDate ofBirthandLegalName
One(1) ofthefollowing documentsmust beshown:
Original orphotocopyofbirthcertificate
Passport
Stateissuedidentificationdocument
US Department of State (I94 Arrival/Departure
Record)
Refugeeresettlementletter (Local sponsoring
agency,USDepartmentofHealthandHumanServices,
OfficeofRefugeeResettlement)Questions?Callthe
InternationalCenter at9803433784
DecreeofAdoption
Student’sdriver’slicense
Lifeinsurancepolicy
Acertifiedcopyofanymedicalrecordofthe child's
birthissuedbythe treatingphysicianorthe hospitalin
whichthechildwasborn
Acertifiedcopyofabirthcertificateissuedbya
church,mosque,temple, orotherreligiousinstitution
thatmaintainsbirthrecordsofitsmembers
Previouslyverifiedschoolrecords
ForProofofResidency
ONE(1)ofthefollowingdocuments must beshown:
Copy of residential deed OR record of most
recentresidentialmortgagestatement
NotarizedResidencyaffidavitfrom
homeowner
/leaseholderaffirmingtenancy
Copyofresidentiallease
HUDclosingstatement
AND
ONE(1)documentfromoneofthefollowingcolumns:
AnyONEutilitybillorworkorderdatedwithinthepast
30Days,including:gas,water,electric,telephone,or
cable
Valid North Carolina Driver’s License OR Valid North
CarolinaIdentificationCARD
Datedwithinthepast30days
o PayrollStub
o BankStatement
o CreditCardStatement
CurrentVehicleRegistration
Datedwithin thePastYear
o VehicleTaxBill
o PropertyTaxBill
o W2
o MedicaidCard
OR
ONE(1)ofthefollowing documents must beshown:
Letterfromapprovedagency (grouphome)
Refugeeresettlementletter
CopyofCharlotteHousingAuthoritylease
Thesedocumentsare foraddressverificationandmustreflectthecurrentaddressforenrollmentorchangeofaddress.CMShasan
appealp
rocessfor familieswhohave difficulty verifying proof ofresidency, sostudentscanbe enrolledwithoutunnecessary delay.Call
StudentPlacementat9803435335ortheInternationalCenterat9803433784formore information.
Thisresidencypolicydoesnotapplytohomelessstudents,asdefinedbytheMcKinneyVentoAct.
For more informationvisitwww.cms.k12.nc.us,emailstudent.placement@cms.k12.nc.usorcall 9803435335
Every Child. Every Day. For a Better Tomorrow.
CHARLOTTE-MECKLENBURG SCHOOLS
Form 7251001 REQUIREMENTS FOR ENROLLMENT
Beforeanystudentis assignedto attendCharlotteMecklenburgSchools (CMS),the student’s parent ,legalguardianorsponsor
(legalguardianshipor sponsorshiprequires additionaldocumentationfrom acourt oragency)mustprovideproofofdateofbirth
andlegal nameandlegal residencein MecklenburgCounty.
ForProofofDate ofBirthandLegalName
One(1) ofthefollowing documentsmustbeshown:
Original orphotocopyofbirthcertificate
Passport
Stateissuedidentificationdocument
US Department of State (I94 Arrival/Departure
Record)
Refugeeresettlementletter (Local sponsoring
agency,USDepartmentofHealthandHumanServices,
OfficeofRefugeeResettlement) Questions? Call the
InternationalCenter at9803433784
DecreeofAdoption
Student’sdriver’slicense
Lifeinsurancepolicy
Acertifiedcopy ofanymedicalrecordofthe child's
birthissuedbythe treatingphysicianorthe hospitalin
whichthechildwasborn
Acertifiedcopyofabirthcertificateissuedbya
church,mosque,temple,orotherreligiousinstitution
thatmaintains birthrecordsofitsmembers
Previouslyverifiedschoolrecords
ForProofofResidency
ONE(1)ofthefollowingdocumentsmust beshown:
Copy of residential deed OR record of most
recentresidentialmortgagestatement
NotarizedResidencyaffidavitfrom
homeowner
/leaseholderaffirmingtenancy
Copyofresidentiallease
HUDclosin
gstatement
AND
ONE(1)documentfromoneof thefollowingcolumns:
AnyONE utility billorwork orderdatedwithinthe past
30Days,including:gas,water,electric,telephone,or
cable
Valid North Carolina Driver’s License OR Valid North
CarolinaIdentificationCARD
Datedwithin thepast 30days
o PayrollStub
o BankStatement
o Credit CardStatement
CurrentVehicleRegistration
Datedwithin thePastYear
o VehicleTaxBill
o PropertyTaxBill
o W2
o MedicaidCard
OR
ONE(1)ofthefollowing documentsmust beshown:
Letterfromapprovedagency (grouphome)
Refugeeresettlementletter
CopyofCharlotte HousingAuthoritylease
Thesedocumentsare foraddressverificationandmustreflectthecurrentaddressforenrollmentorchangeofaddress.CMShasan
appealp
rocessfor familieswhohave difficulty verifying proof ofresidency, sostudentscanbe enrolledwithoutunnecessary delay.Call
StudentPlacementat9803435335ortheInternationalCenterat9803433784formore information.
Thisresidencypolicy does notapply tohomelessstudents, as definedby the McKinneyVento Act.
Formoreinformationvisitwww.cms.k12.nc.us,emailstudent.placement@cms.k12.nc.usorcall9803435335
Every Child. Every Day. For a Better Tomorrow.
CHARLOTTE-MECKLENBURG SCHOOLS
Form 7251001 REQUIREMENTS FOR ENROLLMENT
Beforeanystudentis assignedto attendCharlotteMecklenburgSchools (CMS),the student’s parent ,legalguardianorsponsor
(legalguardianshipor sponsorshiprequires additionaldocumentationfrom acourt oragency) must provideproofofdateofbirth
andlegal nameandlegal residenceinMecklenburgCounty.
ForProofofDate ofBirthandLegalName
One(1) ofthefollowing documents must beshown:
Original orphotocopyofbirthcertificate
Passport
Stateissuedidentificationdocument
US Department of State (I94 Arrival/Departure
Record)
Refugeeresettlementletter(Local sponsoring
agency,USDepartmentofHealthandHumanServices,
OfficeofRefugeeResettlement)Questions? Call the
InternationalCenterat9803433784
DecreeofAdoption
Student’sdriver’slicense
Lifeinsurancepolicy
Acertifiedcopy ofany medicalrecordofthe child's
birthissuedbythe treatingphysicianorthe hospitalin
whichthechildwasborn
Acertifiedcopyofabirthcertificateissuedbya
church,mosque,temple, orotherreligiousinstitution
thatmaintains birthrecordsofitsmembers
Previouslyverifiedschoolrecords
ForProofofResidency
ONE(1)ofthefollowingdocuments must beshown:
Copy of residential deed OR record of most
recentresidentialmortgagestatement
NotarizedResidencyaffidavitfrom
homeowner
/leaseholderaffirmingtenancy
Copyofresidentiallease
HUDclosin
gstatement
AND
ONE(1)documentfromoneof thefollowingcolumns:
AnyONE utility billorwork orderdatedwithinthe past
30Days,including:gas,water,electric,telephone,or
cable
Valid North Carolina Driver’s License OR Valid North
CarolinaIdentificationCARD
Datedwithin thepast 30days
o PayrollStub
o BankStatement
o Credit CardStatement
CurrentVehicleRegistration
Datedwithin thePast Year
o VehicleTaxBill
o PropertyTaxBill
o W2
o MedicaidCard
OR
ONE(1)ofthefollowing documents mustbeshown:
Letterfromapprovedagency (grouphome)
Refugeeresettlementletter
CopyofCharlotte HousingAuthoritylease
Thesedocumentsare foraddressverificationandmustreflectthecurrentaddressforenrollmentorchangeofaddress.CMShasan
appealp
rocessfor familieswhohave difficulty verifying proof ofresidency, sostudentscanbe enrolledwithoutunnecessary delay.Call
StudentPlacementat9803435335ortheInternationalCenterat9803433784formore information.
Thisresidencypolicy does notapply tohomelessstudents, as definedby the McKinneyVento Act.
For more informationvisitwww.cms.k12.nc.us,emailstudent.placement@cms.k12.nc.usorcall 9803435335
Every Child. Every Day. For a Better Tomorrow.
Form 725110.1
Page 2 of 6
Page 1 of 6
CHARLOTTE-MECKLENBURG SCHOOLS
7/2014
Form 725110.1
REQUIREMENTS FOR ENROLLMENT
Before any student is assigned to attend Charlotte-Mecklenburg Schools (CMS), the student’s parent, legal guardian or sponsor
(legal guardianship or sponsorship requires additional documentation from a court or agency) must provide proof of date of birth,
proof of legal name, proof of legal residence in Mecklenburg County, current immunizations, and NC Health Assessment for
students new to a NC public school.
For Proof of Date of Birth and Legal Name
One (1) of the following documents must be shown:
Original or photocopy of birth certificate
Passport
State-issued identification document
US Department of State (I-94 Arrival/Departure
Record)
Refugee resettlement letter (Local sponsoring
agency, US Department of Health and Human Services,
Office of Refugee Resettlement) Questions? Call the
International Center at 980-343-3784
Decree of Adoption
Student’s driver’s license
Life insurance policy
A certified copy of any medical record of the child's
birth issued by the treating physician or the hospital in
which the child was born
A certified copy of a birth certificate issued by a
church, mosque, temple, or other religious institution
that maintains birth records of its members
Previously verified school records
ONE (1) document from one of the following columns:
ONE (1) of the following documents must be shown:
Letter from approved agency (group home)
Refugee resettlement letter
Copy of Charlotte Housing Authority lease
These documents are for address verification and must reflect the current address for enrollment or change of address. CMS has an
appeal process for families who have difficulty verifying proof of residency, so students can be enrolled without unnecessary delay. Call
Student Placement at 980-343-5335 or the International Center at 980-343-3784 for more information.
This residency policy does not apply to homeless students, as defined by the McKinney---Vento Act.
For more information visit www.cms.k12.nc.us, email student.placement@cms.k12.nc.us or call 980‐343‐5335
For Proof of Residency
ONE (1) of the following documents must be shown:
most
AND
Current Vehicle Registration
Dated within the Past Year
o
o
o
W-2
OR
12/2017
CHARLOTTE-MECKLENBURG SCHOOLS
Form 7251001 REQUIREMENTS FOR ENROLLMENT
Beforeanystudentisassigned toattendCharlotteMecklenburg Schools (CMS),thestudent’sparent,legalguardianor sponsor
(legalguardianshiporsponsorshiprequiresadditionaldocumentationfrom acourt oragency) mustprovideproofofdateofbirth
andlegal nameand legal residenceinMecklenburgCounty.
For ProofofDate ofBirthandLegalName
One(1) ofthefollowing documents must beshown:
Original orphotocopyofbirthcertificate
Passport
Stateissuedidentificationdocument
US Department of State (I94 Arrival/Departure
Record)
Refugeeresettlementletter (Local sponsoring
agency,USDepartmentofHealthandHumanServices,
OfficeofRefugeeResettlement)Questions?Callthe
InternationalCenterat9803433784
DecreeofAdoption
Student’sdriver’slicense
Lifeinsurancepolicy
Acertifiedcopy ofany medicalrecordofthe child's
birthissuedbythetreating physicianor the hospitalin
whichthechildwas born
Acertifiedcopyofabirthcertificateissuedbya
church,mosque,temple, orotherreligiousinstitution
thatmaintainsbirthrecords ofits members
Previouslyverifiedschoolrecords
ForProofofResidency
ONE(1)ofthefollowingdocumentsmust beshown:
Copy of residential deed OR record of most
recentresidentialmortgagestatement
NotarizedResidencyaffidavitfrom
homeowner
/leaseholderaffirmingtenancy
Copyofresidentiallease
HUDclosin
gstatement
AND
ONE(1)documentfromoneof thefollowingcolumns:
AnyONE utility billorwork orderdatedwithinthe past
30Days,including:gas,water,electric,telephone,or
cable
Valid North Carolina Driver’s License OR Valid North
CarolinaIdentificationCARD
Datedwithin thepast 30days
o PayrollStub
o BankStatement
o CreditCardStatement
CurrentVehicleRegistration
Datedwithin thePastYear
o VehicleTaxBill
o PropertyTaxBill
o W2
o MedicaidCard
OR
ONE(1)ofthefollowingdocumentsmustbeshown:
Letterfrom approvedagency (grouphome)
Refugeeresettlementletter
CopyofCharlotte HousingAuthoritylease
Thesedocumentsareforaddressverificationandmustreflectthecurrentaddressforenrollmentorchangeofaddress.CMShasan
appealp
rocessforfamilieswhohavedifficulty verifyingproofof residency, sostudentscanbeenrolledwithoutunnecessary delay.Call
StudentPlacementat9803435335or theInternationalCenterat9803433784formore information.
Thisresidency policy does notapply tohomelessstudents, asdefinedbytheMcKinneyVento Act.
For more informationvisitwww.cms.k12.nc.us,emailstudent.placement@cms.k12.nc.usorcall 9803435335
Every Child. Every Day. For a Better Tomorrow.
Thisresidencypolicydoesnotapplytohomelessstudents,asdenedbytheMcKinney-VentoAct.
Formoreinformaonvisitwww.cms.k12.nc.usorcall980-343-5335
CHARLOTTE-MECKLENBURG SCHOOLS
STUDENT ENROLLMENT FORM
Every Child. Every Day. For a Better Tomorrow.
7/2014
Revised 7/2014
Charlotte-Mecklenburg Schools
STUDENT ENROLLMENT FORM
Student Information
Satisfactory proof of age, legal name and residency must be submitted at the time of enrollment
Student’s Legal Last Name
Student’s Legal First Name
Student’s Legal Middle Name
Student’s Preferred Name
Address
Apartment Number
City
State
Zip Code
Home Phone
Cell Phone
Sex
Male Female
Date of Birth (mm/dd/yyyy)
Place of Birth (city, state, county, or country)
Is the student Hispanic or Latino?
Yes No
Which category best describes the student’s race?
American Indian or Alaskan Native Asian Black or African American
Native Hawaiian or other Pacific Islander White
Who does the student live with? (Name and Relationship)
Family Information
Parent 1 Last Name Parent 1 First Name Parent 1 Middle Name
Deceased Yes No
Address same as above
Apartment Number
City
State
Zip Code
Employer
Email
Home Phone
Cell Phone
Business Phone
Parent 2 Last Name Parent 2 First Name Parent 2 Middle Name Parent 2 Maiden Name (If applicable)
Deceased Yes No
Address same as above
Apartment Number
City
State
Zip Code
Employer
Email
Home Phone
Cell Phone
Business Phone
Stepparent Legal Guardian Sponsor Information (check if applicable)
Last Name
First Name
Middle Name
Relationship
Address same as above
Apartment Number
City
State
Zip Code
Employer
Email
Form 7251001
Form 725110.1
Page 3 of 6
Parent 1 Maiden Name (If applicable)
CHARLOTTE-MECKLENBURG SCHOOLS
STUDENT ENROLLMENT FORM
Every Child. Every Day. For a Better Tomorrow.
7/2014
Revised 7/2014
Stepparent, Legal Guardian Sponsor Information—Continued
Home Phone
Cell Phone
Business Phone
Other children in the family enrolled in CMS
Legal Name
School
Grade
Legal Name
School
Grade
Legal Name
School
Grade
Health Information
List pertinent health or medical information and instructions:
Immunization Records Provided Yes No
If no, in compliance with North Carolina law, parents/guardian must present certification of immunizations on the first
day of school entry. If documentation is not presented, parents and/or guardians have 30 calendar days
to provide documentation or the student shall be excluded from school until proof is presented.
Permission for school/nurse to share my child’s shot records with a healthcare provider who needs it when giving my child immunizations.
Yes No
School Information/Academic Placement
Please indicate the student’s current academic placement
New Kindergartener for the ______________ school year New student entering grade ________ for the _____________ school year
New Pre-Kindergartener, please select program: Montessori NC Pre-K/Bright Beginnings EC
Please indicate the student’s previous academic placement
Charter school: in Mecklenburg County outside Mecklenburg County
Private school: in Mecklenburg County outside Mecklenburg County
Public school (other than Charter): in Mecklenburg County outside Mecklenburg County
Group home or other institution Registered Home School Other _______________________________________
Preschool Licensed Childcare Head Start NC Pre-K/Bright Beginnings
None - this is the student’s first academic placement
Last School Attended
Grade
Address
City
State
Zip Code
Date last attended
Month Year
Previous Student ID Number
Has the student ever been enrolled in CMS?
Yes No
If yes, last school attended
School Name School Year
High School Only
Where did the student attend Middle/Junior High?
_______________________________________________________________________________________________________________
Name Address City State
Has your student graduated from high school? Yes No
Form 7251001
Revised 7/2014
Stepparent, Legal Guardian Sponsor Information—Continued
Home Phone
( )
Cell Phone
( )
Business Phone
( )
Other children in the family enrolled in CMS
Legal Name
School
Grade
Legal Name
School
Grade
Legal Name
School
Grade
Health Information
List pertinent health or medical information and instructions:
Immunization Records Provided Yes No
If no, in compliance with North Carolina law, parents/guardian must present certification of immunizations on the first
day of school entry. If documentation is not presented, parents and/or guardians have 30 calendar days
to provide documentation or the student shall be excluded from school until proof is presented.
Permission for school/nurse to share my child’s shot records with a healthcare provider who needs it when giving my child immunizations.
Yes No
School Information/Academic Placement
Please indicate the student’s current academic placement
New Kindergartener for the ______________ school year New student entering grade ________ for the _____________ school year
New Pre-Kindergartener, please select program: Montessori NC Pre-K/Bright Beginnings EC
Please indicate the student’s previous academic placement
Charter school: in Mecklenburg County outside Mecklenburg County
Private school: in Mecklenburg County outside Mecklenburg County
Public school (other than Charter): in Mecklenburg County outside Mecklenburg County
Group home or other institution Registered Home School Other _______________________________________
Preschool Licensed Childcare Head Start NC Pre-K/Bright Beginnings
None - this is the student’s first academic placement
Last School Attended
Grade
Address
City
State
Zip Code
Date last attended
Month Year
Previous Student ID Number
Has the student ever been enrolled in CMS?
Yes No
If yes, last school attended
School Name School Year
High School Only
Where did the student attend Middle/Junior High?
_______________________________________________________________________________________________________________
Name Address City State
Has your student graduated from high school? Yes No
Form 7251001
Revised 7/2014
Stepparent, Legal Guardian Sponsor Information—Continued
Home Phone
( )
Cell Phone
( )
Business Phone
( )
Other children in the family enrolled in CMS
Legal Name
School
Grade
Legal Name
School
Grade
Legal Name
School
Grade
Health Information
List pertinent health or medical information and instructions:
Immunization Records Provided Yes No
If no, in compliance with North Carolina law, parents/guardian must present certification of immunizations on the first
day of school entry. If documentation is not presented, parents and/or guardians have 30 calendar days
to provide documentation or the student shall be excluded from school until proof is presented.
Permission for school/nurse to share my child’s shot records with a healthcare provider who needs it when giving my child immunizations.
Yes No
School Information/Academic Placement
Please indicate the student’s current academic placement
New Kindergartener for the ______________ school year New student entering grade ________ for the _____________ school year
New Pre-Kindergartener, please select program: Montessori NC Pre-K/Bright Beginnings EC
Please indicate the student’s previous academic placement
Charter school: in Mecklenburg County outside Mecklenburg County
Private school: in Mecklenburg County outside Mecklenburg County
Public school (other than Charter): in Mecklenburg County outside Mecklenburg County
Group home or other institution Registered Home School Other _______________________________________
Preschool Licensed Childcare Head Start NC Pre-K/Bright Beginnings
None - this is the student’s first academic placement
Last School Attended
Grade
Address
City
State
Zip Code
Date last attended
Month Year
Previous Student ID Number
Has the student ever been enrolled in CMS?
Yes No
If yes, last school attended
School Name School Year
High School Only
Where did the student attend Middle/Junior High?
_______________________________________________________________________________________________________________
Name Address City State
Has your student graduated from high school? Yes No
Form 7251001
Revised 7/2014
Stepparent, Legal Guardian Sponsor Information—Continued
Home Phone
( )
Cell Phone
( )
Business Phone
( )
Other children in the family enrolled in CMS
Legal Name
School
Grade
Legal Name
School
Grade
Legal Name
School
Grade
Health Information
List pertinent health or medical information and instructions:
Immunization Records Provided Yes No
If no, in compliance with North Carolina law, parents/guardian must present certification of immunizations on the first
day of school entry. If documentation is not presented, parents and/or guardians have 30 calendar days
to provide documentation or the student shall be excluded from school until proof is presented.
Permission for school/nurse to share my child’s shot records with a healthcare provider who needs it when giving my child immunizations.
Yes No
School Information/Academic Placement
Please indicate the student’s current academic placement
New Kindergartener for the ______________ school year New student entering grade ________ for the _____________ school year
New Pre-Kindergartener, please select program: Montessori NC Pre-K/Bright Beginnings EC
Please indicate the student’s previous academic placement
Charter school: in Mecklenburg County outside Mecklenburg County
Private school: in Mecklenburg County outside Mecklenburg County
Public school (other than Charter): in Mecklenburg County outside Mecklenburg County
Group home or other institution Registered Home School Other _______________________________________
Preschool Licensed Childcare Head Start NC Pre-K/Bright Beginnings
None - this is the student’s first academic placement
Last School Attended
Grade
Address
City
State
Zip Code
Date last attended
Month Year
Previous Student ID Number
Has the student ever been enrolled in CMS?
Yes No
If yes, last school attended
School Name School Year
High School Only
Where did the student attend Middle/Junior High?
_______________________________________________________________________________________________________________
Name Address City State
Has your student graduated from high school? Yes No
Form 7251001
Revised 7/2014
Stepparent, Legal Guardian Sponsor Information—Continued
Home Phone
( )
Cell Phone
( )
Business Phone
( )
Other children in the family enrolled in CMS
Legal Name
School
Grade
Legal Name
School
Grade
Legal Name
School
Grade
Health Information
List pertinent health or medical information and instructions:
Immunization Records Provided Yes No
If no, in compliance with North Carolina law, parents/guardian must present certification of immunizations on the first
day of school entry. If documentation is not presented, parents and/or guardians have 30 calendar days
to provide documentation or the student shall be excluded from school until proof is presented.
Permission for school/nurse to share my child’s shot records with a healthcare provider who needs it when giving my child immunizations.
Yes No
School Information/Academic Placement
Please indicate the student’s current academic placement
New Kindergartener for the ______________ school year New student entering grade ________ for the _____________ school year
New Pre-Kindergartener, please select program: Montessori NC Pre-K/Bright Beginnings EC
Please indicate the student’s previous academic placement
Charter school: in Mecklenburg County outside Mecklenburg County
Private school: in Mecklenburg County outside Mecklenburg County
Public school (other than Charter): in Mecklenburg County outside Mecklenburg County
Group home or other institution Registered Home School Other _______________________________________
Preschool Licensed Childcare Head Start NC Pre-K/Bright Beginnings
None - this is the student’s first academic placement
Last School Attended
Grade
Address
City
State
Zip Code
Date last attended
Month Year
Previous Student ID Number
Has the student ever been enrolled in CMS?
Yes No
If yes, last school attended
School Name School Year
High School Only
Where did the student attend Middle/Junior High?
_______________________________________________________________________________________________________________
Name Address City State
Has your student graduated from high school? Yes No
Form 7251001
Revised 7/2014
Stepparent, Legal Guardian Sponsor Information—Continued
Home Phone
( )
Cell Phone
( )
Business Phone
( )
Other children in the family enrolled in CMS
Legal Name
School
Grade
Legal Name
School
Grade
Legal Name
School
Grade
Health Information
List pertinent health or medical information and instructions:
Immunization Records Provided Yes No
If no, in compliance with North Carolina law, parents/guardian must present certification of immunizations on the first
day of school entry. If documentation is not presented, parents and/or guardians have 30 calendar days
to provide documentation or the student shall be excluded from school until proof is presented.
Permission for school/nurse to share my child’s shot records with a healthcare provider who needs it when giving my child immunizations.
Yes No
School Information/Academic Placement
Please indicate the student’s current academic placement
New Kindergartener for the ______________ school year New student entering grade ________ for the _____________ school year
New Pre-Kindergartener, please select program: Montessori NC Pre-K/Bright Beginnings EC
Please indicate the student’s previous academic placement
Charter school: in Mecklenburg County outside Mecklenburg County
Private school: in Mecklenburg County outside Mecklenburg County
Public school (other than Charter): in Mecklenburg County outside Mecklenburg County
Group home or other institution Registered Home School Other _______________________________________
Preschool Licensed Childcare Head Start NC Pre-K/Bright Beginnings
None - this is the student’s first academic placement
Last School Attended
Grade
Address
City
State
Zip Code
Date last attended
Month Year
Previous Student ID Number
Has the student ever been enrolled in CMS?
Yes No
If yes, last school attended
School Name School Year
High School Only
Where did the student attend Middle/Junior High?
_______________________________________________________________________________________________________________
Name Address City State
Has your student graduated from high school? Yes No
Form 7251001
Revised 7/2014
Stepparent, Legal Guardian Sponsor Information—Continued
Home Phone
( )
Cell Phone
( )
Business Phone
( )
Other children in the family enrolled in CMS
Legal Name
School
Grade
Legal Name
School
Grade
Legal Name
School
Grade
Health Information
List pertinent health or medical information and instructions:
Immunization Records Provided Yes No
If no, in compliance with North Carolina law, parents/guardian must present certification of immunizations on the first
day of school entry. If documentation is not presented, parents and/or guardians have 30 calendar days
to provide documentation or the student shall be excluded from school until proof is presented.
Permission for school/nurse to share my child’s shot records with a healthcare provider who needs it when giving my child immunizations.
Yes No
School Information/Academic Placement
Please indicate the student’s current academic placement
New Kindergartener for the ______________ school year New student entering grade ________ for the _____________ school year
New Pre-Kindergartener, please select program: Montessori NC Pre-K/Bright Beginnings EC
Please indicate the student’s previous academic placement
Charter school: in Mecklenburg County outside Mecklenburg County
Private school: in Mecklenburg County outside Mecklenburg County
Public school (other than Charter): in Mecklenburg County outside Mecklenburg County
Group home or other institution Registered Home School Other _______________________________________
Preschool Licensed Childcare Head Start NC Pre-K/Bright Beginnings
None - this is the student’s first academic placement
Last School Attended
Grade
Address
City
State
Zip Code
Date last attended
Month Year
Previous Student ID Number
Has the student ever been enrolled in CMS?
Yes No
If yes, last school attended
School Name School Year
High School Only
Where did the student attend Middle/Junior High?
_______________________________________________________________________________________________________________
Name Address City State
Has your student graduated from high school? Yes No
Form 7251001
Revised 7/2014
Stepparent, Legal Guardian Sponsor Information—Continued
Home Phone
( )
Cell Phone
( )
Business Phone
( )
Other children in the family enrolled in CMS
Legal Name
School
Grade
Legal Name
School
Grade
Legal Name
School
Grade
Health Information
List pertinent health or medical information and instructions:
Immunization Records Provided es No
If no, in compliance with North Carolina law, parents/guardian must present certification of immunizations on the first
day of school entry. If documentation is not presented, parents and/or guardians have 30 calendar days
to provide documentation or the student shall be excluded from school until proof is presented.
Permission for school/nurse to share my child’s shot records with a healthcare provider who needs it when giving my child immunizations.
Yes No
School Information/Academic Placement
Please indicate the student’s current academic placement
New Kindergartener for the ______________ school year New student entering grade ________ for the _____________ school year
New Pre-Kindergartener, please select program: Montessori NC Pre-K/Bright Beginnings EC
Please indicate the student’s previous academic placement
Charter school: in Mecklenburg County outside Mecklenburg County
Private school: in Mecklenburg County outside Mecklenburg County
Public school (other than Charter): in Mecklenburg County outside Mecklenburg County
Group home or other institution Registered Home School Other _______________________________________
Preschool Licensed Childcare Head Start NC Pre-K/Bright Beginnings
None - this is the student’s first academic placement
Last School Attended
Grade
Address
City
State
Zip Code
Date last attended
Month Year
Previous Student ID Number
Has the student ever been enrolled in CMS?
Yes No
If yes, last school attended
School Name School Year
High School Only
Where did the student attend Middle/Junior High?
_______________________________________________________________________________________________________________
Name Address City State
Has your student graduated from high school? Yes No
Form 7251001
Revised 7/2014
Stepparent, Legal Guardian Sponsor Information—Continued
Home Phone
)
Cell Phone
( )
Business Phone
( )
Other children in the family enrolled in CMS
Legal Name
School
Grade
Legal Name
School
Grade
Legal Name
School
Grade
Health Information
List pertinent health or medical information and instructions:
Immunization Records Provided Yes No
If no, in compliance with North Carolina law, parents/guardian must present certification of immunizations on the first
day of school entry. If documentation is not presented, parents and/or guardians have 30 calendar days
to provide documentation or the student shall be excluded from school until proof is presented.
Permission for school/nurse to share my child’s shot records with a healthcare provider who needs it when giving my child immunizations.
Yes No
School Information/Academic Placement
Please indicate the student’s current academic placement
New Kindergartener for the ______________ school year New student entering grade ________ for the _____________ school year
New Pre-Kindergartener, please select program: Montessori NC Pre-K/Bright Beginnings EC
Please indicate the student’s previous academic placement
Charter school: in Mecklenburg County outside Mecklenburg County
Private school: in Mecklenburg County outside Mecklenburg County
Public school (other than Charter): in Mecklenburg County outside Mecklenburg County
Group home or other institution Registered Home School Other _______________________________________
Preschool Licensed Childcare Head Start NC Pre-K/Bright Beginnings
None - this is the student’s first academic placement
Last School Attended
Grade
Address
City
State
Zip Code
Date last attended
Month Year
Previous Student ID Number
Has the student ever been enrolled in CMS?
Yes No
If yes, last school attended
School Name School Year
High School Only
Where did the student attend Middle/Junior High?
_______________________________________________________________________________________________________________
Name Address City State
Has your student graduated from high school? Yes No
Form 7251001
Form 725110.1
Page 4 of 6
CHARLOTTE-MECKLENBURG SCHOOLS
STUDENT ENROLLMENT FORM
7/2014
Revised 7/2014
Parent/Legal Guardian _____________________________________________________________ Date __________________________
This form must be signed and submitted with your child’s proof of age and legal name, proofs of residency and Safe Schools
Enrollment Declaration.
For Office Use Only
Student ID _________________________________________
Enrollment Date ____________________ Grade _________
Registration Completion Date __________________________
School __________________________________________
Immunization Record
Yes

No
Transportation ____________________________________
Proof of Age/Legal Name Yes No
Teacher’s Name ________________________________
Proof of Residency Yes No
Previous School Records Yes No
School Receiving Packet ____________________________
Name of Person Receiving Packet __________________
Referred to International Center 980-343-3784 Date________________ By ___________________________________
Does your child have an Individualized Education Program (IEP)? Yes No
Does your child have a 504 Educational Plan? Yes No
Federal and state polices require schools to determine the language(s) spoken at home by each student. If the answer to any of the questions below is
a language other than English, your child may be assessed on the WIDA ACCESS Placement Test (W-APT) to determine English language proficiency.
Based on the results, your child may be identified as Limited English Proficient (LEP) and qualify for English Language Learner (ELL) services.
Date your child first attended K-12 school in the U.S. (do not include Pre-K)
What language does your son/daughter most frequently use to communicate?
What language did your son/daughter learn when he/she first began to talk?
What language do you most frequently speak to your son/daughter?
Do you need an interpreter for school meetings involving your child’s education?
Yes No If yes, in which language? __________________________________
Custody
Do you have legal custody of this child? Yes No
Are both parents authorized to pick up the child from school? Yes No If no, please provide legal documentation
Emergency Contact Information Please provide information for contacts, other than parents
Emergency Contact ___________________________________________________________________________(______)_____________________
(Other than Parent) Name Relationship Phone
Can this person pick up the student from school? Yes No
Emergency Contact ___________________________________________________________________________(______)_____________________
(Other than Parent) Name Relationship Phone
Can this person pick up the student from school? Yes No
Emergency Contact ___________________________________________________________________________(______)_____________________
(Other than Parent) Name Relationship Phone
Can this person pick up the student from school? Yes No
Required Parent/Legal Guardian Signature
Revised 7/2014
Parent/Legal Guardian _____________________________________________________________ Date __________________________
This form must be signed and submitted with your child’s proof of age and legal name, proofs of residency and Safe Schools
Enrollment Declaration.
For Office Use Only
Student ID _________________________________________
Enrollment Date ____________________ Grade _________
Registration Completion Date __________________________
School __________________________________________
Immunization Record
Yes

No
Transportation ____________________________________
Proof of Age/Legal Name Yes No
Teacher’s Name ________________________________
Proof of Residency Yes No
Previous School Records Yes No
School Receiving Packet ____________________________
Name of Person Receiving Packet __________________
Referred to International Center 980-343-3784 Date________________ By ___________________________________
IEP)? Yes No
Does your child have a 504 Educational Plan? Yes No
Home Language Survey
Federal and state polices require schools to determine the language(s) spoken at home by each student. If the answer to any of the questions below is
a language other than English, your child may be assessed on the WIDA ACCESS Placement Test (W-APT) to determine English language proficiency.
Based on the results, your child may be identified as Limited English Proficient (LEP) and qualify for English Language Learner (ELL) services.
Date your child first attended K-12 school in the U.S. (do not include Pre-K)
What language does your son/daughter most frequently use to communicate?
What language did your son/daughter learn when he/she first began to talk?
What language do you most frequently speak to your son/daughter?
Do you need an interpreter for school meetings involving your child’s education?
Yes No If yes, in which language? __________________________________
Custody
Do you have legal custody of this child? Yes No
Are both parents authorized to pick up the child from school? Yes No If no, please provide legal documentation
Emergency Contact Information Please provide information for contacts, other than parents
Emergency Contact ___________________________________________________________________________(______)_____________________
(Other than Parent) Name Relationship Phone
Can this person pick up the student from school? Yes No
Emergency Contact ___________________________________________________________________________(______)_____________________
(Other than Parent) Name Relationship Phone
Can this person pick up the student from school? Yes No
Emergency Contact ___________________________________________________________________________(______)_____________________
(Other than Parent) Name Relationship Phone
Can this person pick up the student from school? Yes No
Required Parent/Legal Guardian Signature
Revised 7/2014
Parent/Legal Guardian _____________________________________________________________ Date __________________________
This form must be signed and submitted with your child’s proof of age and legal name, proofs of residency and Safe Schools
Enrollment Declaration.
For Office Use Only
Student ID _________________________________________
Enrollment Date ____________________ Grade _________
Registration Completion Date __________________________
School __________________________________________
Immunization Record
Yes

No
Transportation ____________________________________
Proof of Age/Legal Name Yes No
Teacher’s Name ________________________________
Proof of Residency Yes No
Previous School Records Yes No
School Receiving Packet ____________________________
Name of Person Receiving Packet __________________
Referred to International Center 980-343-3784 Date________________ By ___________________________________
Does your child have an Individualized Education Program (IEP)? Yes No
Does your child have a 504 Educational Plan? Yes No
Home Language Survey
Federal and state polices require schools to determine the language(s) spoken at home by each student. If the answer to any of the questions below is
a language other than English, your child may be assessed on the WIDA ACCESS Placement Test (W-APT) to determine English language proficiency.
Based on the results, your child may be identified as Limited English Proficient (LEP) and qualify for English Language Learner (ELL) services.
Date your child first attended K-12 school in the U.S. (do not include Pre-K)
What language does your son/daughter most frequently use to communicate?
What language did your son/daughter learn when he/she first began to talk?
What language do you most frequently speak to your son/daughter?
Do you need an interpreter for school meetings involving your child’s education?
Yes No If yes, in which language? __________________________________
Custody
Do you have legal custody of this child? Yes No
Are both parents authorized to pick up the child from school? Yes No If no, please provide legal documentation
Emergency Contact Information Please provide information for contacts, other than parents
Emergency Contact ___________________________________________________________________________(______)_____________________
(Other than Parent) Name Relationship Phone
Can this person pick up the student from school? Yes No
Emergency Contact ___________________________________________________________________________(______)_____________________
(Other than Parent) Name Relationship Phone
Can this person pick up the student from school? Yes No
Emergency Contact ___________________________________________________________________________(______)_____________________
(Other than Parent) Name Relationship Phone
Can this person pick up the student from school? Yes No
Required Parent/Legal Guardian Signature
Revised 7/2014
Parent/Legal Guardian _____________________________________________________________ Date __________________________
This form must be signed and submitted with your child’s proof of age and legal name, proofs of residency and Safe Schools
Enrollment Declaration.
For Office Use Only
Student ID _________________________________________
Enrollment Date ____________________ Grade _________
Registration Completion Date __________________________
School __________________________________________
Immunization Record Yes No
Transportation ____________________________________
Proof of Age/Legal Name Yes No
Teacher’s Name ________________________________
Proof of Residency Yes No
Previous School Records Yes No
School Receiving Packet ____________________________
Name of Person Receiving Packet __________________
Referred to International Center 980-343-3784 Date________________ By ___________________________________
Federal and state polices require schools to determine the language(s) spoken at home by each student. If the answer to any of the questions below is
assessed on the WIDA ACCESS Placement Test (W-APT) to determine English language proficiency.
d on the results, your child may be identified as Limited English Proficient (LEP) and qualify for English Language Learner (ELL) services.
Date your child first attended K-12 school in the U.S. (do not include Pre-K)
What language does your son/daughter most frequently use to communicate?
What language did your son/daughter learn when he/she first began to talk?
What language do you most frequently speak to your son/daughter?
Do you need an interpreter for school meetings involving your child’s education?
Yes No If yes, in which language? __________________________________
Custody
Do you have legal custody of this child? Yes No
Are both parents authorized to pick up the child from school? Yes No If no, please provide legal documentation
Emergency Contact Information Please provide information for contacts, other than parents
Emergency Contact ___________________________________________________________________________(______)_____________________
(Other than Parent) Name Relationship Phone
Can this person pick up the student from school? Yes No
Emergency Contact ___________________________________________________________________________(______)_____________________
(Other than Parent) Name Relationship Phone
Can this person pick up the student from school? Yes No
Emergency Contact ___________________________________________________________________________(______)_____________________
(Other than Parent) Name Relationship Phone
Can this person pick up the student from school? Yes No
Required Parent/Legal Guardian Signature
Form 7251001
Revised 7/2014
Parent/Legal Guardian _____________________________________________________________ Date __________________________
This form must be signed and submitted with your child’s proof of age and legal name, proofs of residency and Safe Schools
Enrollment Declaration.
For Office Use Only
Student ID _________________________________________
Enrollment Date ____________________ Grade _________
Registration Completion Date __________________________
School __________________________________________
Immunization Record Yes No
Transportation ____________________________________
Proof of Age/Legal Name Yes No
Teacher’s Name ________________________________
Proof of Residency Yes No
Previous School Records Yes No
School Receiving Packet ____________________________
Name of Person Receiving Packet __________________
Referred to International Center 980-343-3784 Date________________ By ___________________________________
termine the language(s) spoken at home by each student. If the answer to any of the questions below is
ay be assessed on the WIDA ACCESS Placement Test (W-APT) to determine English language proficiency.
fied as Limited English Proficient (LEP) and qualify for English Language Learner (ELL) services.
Date your child first attended K-12 school in the U.S. (do not include Pre-K)
What language does your son/daughter most frequently use to communicate?
What language did your son/daughter learn when he/she first began to talk?
What language do you most frequently speak to your son/daughter?
Do you need an interpreter for school meetings involving your child’s education?
Yes No If yes, in which language? __________________________________
Custody
Do you have legal custody of this child? Yes No
Are both parents authorized to pick up the child from school? Yes No If no, please provide legal documentation
Emergency Contact Information Please provide information for contacts, other than parents
Emergency Contact ___________________________________________________________________________(______)_____________________
(Other than Parent) Name Relationship Phone
Can this person pick up the student from school? Yes No
Emergency Contact ___________________________________________________________________________(______)_____________________
(Other than Parent) Name Relationship Phone
Can this person pick up the student from school? Yes No
Emergency Contact ___________________________________________________________________________(______)_____________________
(Other than Parent) Name Relationship Phone
Can this person pick up the student from school? Yes No
Required Parent/Legal Guardian Signature
Form 7251001
Form 725110.1
Page 5 of 6
CHARLOTTE-MECKLENBURG SCHOOLS
SAFE SCHOOLS ENROLLMENT DECLARATION
North Carolina General Statute 115C-366 (a4) requires that parents, guardians, or legal custodians of all students who transfer
into Charlotte-Mecklenburg Schools provide a statement as to whether the student is, under suspension or expulsion from
attendance at a private or public school in this or any other state or has been convicted of a felony in this or any other state.
This does not apply to a student who has never been enrolled in or attended a private or public school in this or any other state.
Enrolling Student Information
Suspensions and Expulsions
Name
Parent/Guardian/Legal Custodian Name:
Home/Cell/Work Phone:
Please check the appropriate box as it relates to the student named above.
(school). Explain offense and pending discipline.
Last First Middle
Address
Date of Birth Age Grade
IS NOT currently suspended or expelled from any school and does not have a pending suspension or explusion
Has been recommended for long term (more than 10 days) suspension or expulsion from
(school).
Has been long-term suspended or expelled from
Street City State Zip Code
Explain offense and pending discipline.
Address of Previous School:
Previous School Telephone:
Convicted of:
in (City, Town, & State):
Date of Conviction:
Description of offense:
Probation Officer:
Court Counselor:
Phone:
Phone:
Felony Convictions
Please check the appropriate box as it relates to the student named above.
HAS NOT been convicted of a felony in this or any other state.
Has been convicted of a felony.
I, ________________________________________(Parent/Guardian/Legal Custodian) hereby swear or affirm that the
above information is true and accurate.
North Carolina General Statute 115C-366 (a4) requires that parents, guardians, or legal custodians of all students who transfer
into Charlotte-Mecklenburg Schools provide a statement as to whether the student is, under suspension or expulsion from
attendance at a private or public school in this or any other state or has been convicted of a felony in this or any other state.
This does not apply to a student who has never been enrolled in or attended a private or public school in this or any other state.
Enrolling Student Information
Suspensions and Expulsions
Name
Parent/Guardian/Legal Custodian Name:
Home/Cell/Work Phone:
Please check the appropriate box as it relates to the student named above.
(school). Explain offense and pending discipline.
Last First Middle
Address
Date of Birth Age Grade
IS NOT currently suspended or expelled from any school and does not have a pending suspension or explusion
Has been recommended for long term (more than 10 days) suspension or expulsion from
(school).
Has been long-term suspended or expelled from
Street City State Zip Code
Explain offense and pending discipline.
Address of Previous School:
Previous School Telephone:
Convicted of:
in (City, Town, & State):
Date of Conviction:
Description of offense:
Probation Officer:
Court Counselor:
Phone:
Phone:
Felony Convictions
Please check the appropriate box as it relates to the student named above.
HAS NOT been convicted of a felony in this or any other state.
Has been convicted of a felony.
I, ________________________________________(Parent/Guardian/Legal Custodian) hereby swear or affirm that the
above information is true and accurate.
North Carolina General Statute 115C-366 (a4) requires that parents, guardians, or legal custodians of all students who transfer
into Charlotte-Mecklenburg Schools provide a statement as to whether the student is, under suspension or expulsion from
attendance at a private or public school in this or any other state or has been convicted of a felony in this or any other state.
This does not apply to a student who has never been enrolled in or attended a private or public school in this or any other state.
Enrolling Student Information
Suspensions and Expulsions
Name
Parent/Guardian/Legal Custodian Name:
Home/Cell/Work Phone:
Please check the appropriate box as it relates to the student named above.
(school). Explain offense and pending discipline.
Last First Middle
Address
Date of Birth Age Grade
IS NOT currently suspended or expelled from any school and does not have a pending suspension or explusion
Has been recommended for long term (more than 10 days) suspension or expulsion from
(school).
Has been long-term suspended or expelled from
Street City State Zip Code
Explain offense and pending discipline.
Address of Previous School:
Previous School Telephone:
Convicted of:
in (City, Town, & State):
Date of Conviction:
Description of offense:
Probation Officer:
Court Counselor:
Phone:
Phone:
Felony Convictions
Please check the appropriate box as it relates to the student named above.
HAS NOT been convicted of a felony in this or any other state.
Has been convicted of a felony.
I, ________________________________________(Parent/Guardian/Legal Custodian) hereby swear or affirm that the
above information is true and accurate.
Page 6 of 6
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Form 725110.1: CHARLOTTE-MECKLENBURG SCHOOLS

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Completed 9 August 2021

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