C. Schmidt – March 11, 2008 Reference Policy 5111

Custodial Placement - Enrolling Parent Form

Please return this form to the school whether applicable or not. If not applicable – please check this circle with an X - N/A

_________________________________________________________________________________________ _____________ Parent Signature Date

Is there any Court Order dealing with the custody or visitation of the following child (ren)? Yes No List the other party to the action affecting the child (ren) listed below: _____________________________________________________________________________________ Name Telephone # _____________________________________________________________________________________ Address City State Please check one:

I have full custody and primary physical placement of the children listed on this form (attach Court Order). I have joint custody and primary physical placement of the children listed on this form as described in most recent

Court Order of custody and placement (attach Court Order). I have joint custody and shared physical placement of the children listed on this form as described in most recent Court

Order of custody and placement (attach Court Order). I do not have either of the above arrangements. Please see the most recent Court Order of custody and placement for

details (attach Court Order). Does the most recent Court Order curtail or restrict the rights and privileges of the other parent to be kept advised of the child(ren)'s school progress and school activities or participation? Yes (attach Court Order) No

Does the most recent Court Order definitely prohibit the school to release the child (ren) to the other parent? Yes (attach Court Order) No ____________________________________________________________________________ Name of Enrolling Parent/Guardian Date _____________________________________________________________________________________ Address City State Telephone # List full name(s) of child (ren) affected by Court Order and the school attending: _____________________________________________________________________________________ First full name Middle name Last name School ______________________________________________________________________________________________________ First full name Middle name Last name School ______________________________________________________________________________________________________ First full name Middle name Last name School ______________________________________________________________________________________________________ First full name Middle name Last name School ______________________________________________________________________________________________________ First full name Middle name Last name School