Fillable New Student Registration Checklist for Parent(s) / Legal

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New Student Registration Checklist for Parent(s) / Legal

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Notes:
*Verication of Address – Parents / Legal guardians must provide TWO of the following:
Broker’s or Attorney’s statement of parents’ purchase of residence, or properly executed
lease agreement
Current Homestead Exemption Card
Electric deposit receipt or electric bill, showing name and service address
Miami-Dade County Public Schools Statement of Bonade Residence – FM-7444
Parents / Legal guardians send an email registration request to the Principal at the student’s
assigned school based on residence. Follow this LINK for a directory of M-DCPS Principal
emails. Include in the email:
Email subject line: NEW STUDENT REGISTRATION
Full Name of Parent/ Legal Guardian registering student
Parent/ Legal Guardian’s Home Address
Parent/ Legal Guardian Contact Information: Email and Phone #
Student Information:
Full Name
Date of Birth
Grade for the 2020- 2021 School Year
Parents / Legal guardians must provide these documents at the time of registration:
Verication of Age and legal name
Verication of parent/legal guardian current residence*
Health and immunization Requirement
Parents / Legal guardians must complete the following forms (included in this packet)
at time of registration:
Home Language Survey Form (FM-5196)
Disclosure at Time of Registration (FM-5740)
Emergency Student Data Form (FM-2733)
Project UP-START Student Questionnaire (FM-7378)
New Student Registration Checklist
for Parent(s) / Legal Guardian(s)
Miami-Dade County Public Schools
Federal and State Compliance Oce
FASCO 5/6/2020
MIAMI-DADE COUNTY PUBLIC SCHOOLS
HOME LANGUAGE SURVEY
To Be Completed By Parent or Guardian
Student I.D. No.________________________
1. Is a language other than English used in the home? Yes ____ No____
2. Did the student have a first language other than English? Yes ____ No____
3. Does the student most frequently speak a language other than English? Yes ____ No____
If the answer is "YES" to any of these questions, the student must be tested for English proficiency.
School ______________________________________ Date ________________ Parent/Guardian Signature________________________________
Date of Birth _______________________ Grade_______ Parent Language _______________________ Student Language ____________________
Month Day Year
Student Name _________________________________________ ___________________________________________ ______________________
Last First Middle
//
Date Entered U.S. School : _____________________
Month Day Year
//
ESCUELAS PUBLICAS DEL CONDADO DE MIAMI-DADE
ENCUESTA SOBRE EL IDIOMA HABLADO EN EL HOGAR
Debe ser completado por el/la padre/madre o tutor/a
No. De I.D. _________________________
1. ¿Usan en su casa algún otro idioma que no sea el Inglés? Sí _____ No _____
2. ¿Tuvo el estudiante una lengua materna distinta al Inglés? Sí _____ No _____
3. ¿Habla el estudiante frecuentemente otro idioma que no sea el Inglés? Sí _____ No _____
Si responde "Sí" a alguna de estas preguntas, el estudiante debe tomar un examen para saber cual es
su conocimiento del Inglés.
Escuela ____________________________________________ Fecha _____________ Firma del Padre/Madre ___________________________________
Nombre del Estudiante ________________________________________ _______________________________ __________________________
Apellido Nombre Inicial
Fecha de Nacimiento ___________________ Grado ______ Lengua Paterna ____________________ Idioma del Estudiante _________________
Mes Día Año
/ /
Fecha de Entrada a la Escuela de los Estados Unidos: _____________________
Mes Dia
Año
/ /
MIAMI-DADE COUNTY PUBLIC SCHOOLS
SONDAJ SOU KI LANG TIMOUN NAN PALE
Pou paran oubyen moun ki responsab timoun nan ranpli
No. I.D. Elèv La _________________
Dat Fèt li ____________________________ Klas _____ Lang paran Yo __________________________ Lang Elèv La ______________________
Mwa Jou Ane
1. Eske yo sèvi ak yon lang ki pa Anglè lakay li? Wi ____ Non ____
2. Eske elèv la te genyen yon premye lang anvan Anglè? Wi ____ Non ____
3. Eske elèv la abitye pale yon lang ki pa Anglè? Wi ____ Non ____
Si repons lan se "WI" pou nenpòt nan kesyon anba yo, elèv la dwe pran yon tès Anglè.
Lekòl ___________________________________________Dat ________________ Siyati Paran __________________________________________
Non Elèv la _______________________________________________________
______________________________________________________
Non fanmi Non
//
FM-5196ESH Rev. (08-19)
Dat ou Antre U.S. Lekòl: ______________________
/ /
Mwa Jou Ane
CC: FILE IN CUMULATIVE FOLDER
TO STAFF FOR TESTING
(Check all
that apply)
White
Black
Asian
Race:
American Indian Native Pacific Islander
(Marque
todo lo pertinente) Blanco
Negro
Raza:
Indígena de los EEUU Oriundo de las Islas del Pacífico
Etnisite
Espayòl ______ (W/N)
(Tcheke tout
sa ki aplike)
Blan
Nwa
Azyatik
Ras:
Amriken Endyen Natif Il Pasifik
Asiático
Ethnic
Hispanic ______ (Y/N)
Origen Etnico
Hispano ______ (S/N)
Clear Form
MIAMI-DADE COUNTY PUBLIC SCHOOLS
DISCLOSURE AT TIME OF REGISTRATION
Chapter 1006.07 (1)(b), requires that any student seeking admission to a public school in the State of
Florida will provide the following information at the time of initial registration:
1)
Has the student ever been expelled from any school, in or out of the State of Florida?
YES
NO
If your answer to question 1 is "YES", please list each and every instance for which the student was
expelled.
2)
Please state whether the student has ever been arrested where the arrest resulted in the student
being formally charged. If your answer is "YES", please list each and every arrest which
resulted in a formal charge.
3)
Please state whether the student has ever been involved as a party in a case before the Juvenile
Justice System? If so, state each action taken by the Juvenile Justice System which involved the
student.
4)
Please state whether the student has any corresponding referrals to mental health services related
to your answers to Questions 1, 2 and 3. If yes, please list them.
Student's Name ID. #
(Please Print)
Ethnic
Hispanic (Y/N)
(Check all
that apply)
Race: White
Black
American Indian
Asian
Native Pacific Islander
Date of Birth Parent's/Guardian's Name
Address
Signature (Parent/Guardian)
Signature (Student) Date Signed
FM-5740E Rev. (07-19)
Clear Form
EMERGENCY STUDENT DATA FORM
FM-2733E Rev. (06-19)
2000611
Parents/guardians have the right to review the professional qualifications of their child's classroom teacher(s) including the licensing status, degree major, graduate degree(s)
and the field of certification. This "right to know", available from your child's school, includes whether your child is receiving services provided by paraprofessionals and, if so,
their qualifications.
Whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his/her official duty shall be guilty of a misdemeanor of
the second degree under Fla. Stat § 837.06, or whoever makes a false verified declaration is guilty of the crime of perjury, a felony of the third degree, under Fla. Stat. § 95.525,
which are punishable as provided in Fla. Stat., §§ 775.082, 775.083 and 775.084.
The Emergency Student Data Form governs early release withdraw of the student. The registering parent/guardian must sign/verify this form and is responsible for providing
truthful and accurate information. If the student's parents are divorced or separated, the enrolling parent is responsible for providing information that is consistent with the most
recent court order governing such matters as divorce, separation or custody.
School No./Name SectionI.D. No. Grade
Student's Last Name Middle NameFirst NameAPP
Address
Main contact phone number to be used for emergencies and automated messaging:
Registering Parent/Guardian's Name Relation Place of Employment
Telephone Cellphone Email
Non-Registering Parent/Guardian's Name Relation Place of Employment
Telephone Cellphone Email
Is either parent in the Military? Yes ____ No ____ Branch _______________________________________________________
Kindergarten Only: Was the child in pre-school or child care? Yes ______ No ______
Was the full cost paid by you? Yes ____ No ____ What type? Headstart ____ ESE ____ Migrant _____ Other ____ Unknown ____
EMERGENCY CONTACT INFORMATION: I authorize the school district to provide or secure any necessary emergency care for my
child. It is the parent's legal responsibility to assume medical and transportation expenses for your child. In the event that parents of
child cannot be reached, provide contact information below of two persons, by order of priority.
(Phone at Work)(Relation to Student) (Address)(Name)
(Phone at Work)(Relation to Student) (Address)(Name)
PhonePhone Preference of HospitalFamily Doctor
Student health/allergy data which should be known in an emergency:
AUTHORIZATION FOR RELEASE OF STUDENTS FROM SCHOOL: Please provide the names of persons authorized or not
authorized to take your child from school during the school day. Note that persons listed as emergency contacts are not authorized
to pick up your child, unless listed in this section.
Authorized:
Authorized:
Not authorized:
Not authorized:
IT IS THE PARENT'S RESPONSIBILITY to inform the school in person of any changes in the information listed on this form. Under
penalties of perjury, I declare that I have read the foregoing [document] and that the facts stated in it are true.
Date:
Printed Registering Parent/Guardian's Name
Registering Parent/Guardian's Signature
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Clear Form
(A) (H)
(F)
(B) (S)
(T)
(D) (D)
(M)
(O)
(E)
(U)
Grade
The undersigned certifies that the information provided is accurate.
Date
SECTION D: Parents, Guardians and/or Unaccompanied Youth must complete this section, prior to
submitting the Questionnaire for processing.
SECTION B: The student does NOT currently have housing that is Fixed, Regular, and Adequate.
Please continue below if your child is a student that:
no electricity/mold infested)
The current nighttime residence is... (check only one)
Was displaced from household because of... (check only one)
campground, parks, abandoned buildings, public
mental illness, unemployment, domestic violence
Date of Birth
p Living in a vehicle of any kind, trailer park or
p
In emergency or transitional shelters, FEMA
trailers, or abandoned in hospitals
p Temporarily sharing the housing of other
persons due to economic hardship
SECTION A: The student currently has housing that is Fixed, Regular, and Adequate.
Miami-Dade County Public Schools
Department of Title I Administration
Children and Youth in Transition Program
Project UP-START Student Eligibility Questionnaire
This questionnaire is intended to help determine eligibility of services under the federal McKinney-Vento Act. Florida Statute 837.06
provides that whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his
official duty shall be guilty of a misdemeanor of second degree.
Parent/Guardian Initial:___________________
Student Name: _________________________
Student ID#: ___________________________
Please do not continue completing this form if you checked
one of the boxes above.
Project UP-START services are confidential and this form is not to be shared with outside community agencies.
p Student is living alone without an adult. p Student is living with an adult that is NOT a parent/guardian.
FM-7378E Rev. (08-19)
Current Address: ___________________________________ Apt: ______ City: __________________
Zip: __________________
Signature of Parent/Guardian OR Unaccompanied Student
Please complete the FM-7402 (Caregiver's Authorization Form).
SCHOOL/AGENCY STAFF CONTACT INFORMATION
SCHOOL/AGENCY STAFF USE ONLY
Caregiver Name: ________________________________________________
Contact Phone: ______________________________________ Email: ________________________________________________
Name of Parent/Guardian: ______________________________________________
Date: _______________________
SECTION C: Unaccompanied Youth must complete this section.
Please fax the following completed forms to 305 579-0370, via email to projectupstart@dadeschools.net, or send forms to
Location #9102:
Staff Name: ___________________________________ Telephone #: ________________________
Fax/Email Date: _______________________________
School/Agency Name: _______________________________________________________________
Location #: _______________
Extension: ______________
► FM-7378
► FM-7402, FM-7404, and FM-7405, as applicable
Student Name (Last, First)
p In a motel/hotel due to loss of housing,
economic hardship, or similar reason
Please list the names of all students who are active in M-DCPS.
Student ID#
place, or substandard housing (e.g. no running water
Clear Form
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New Student Registration Checklist for Parent(s) Legal

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Completed 28 September 2020

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